SAD is characterized by a persistent fear that in social and performance situations the individual will say or do something that will lead to humiliation, embarrassment, or negative evaluation by others Table 19 [ 26 ]. Social situations are actively avoided or endured with distress, and the individual recognizes the fears as excessive or unreasonable. The avoidance or anxiety induced by these fears incurs significant functional impairment and distress [ ]. Some patients experience excessive social anxiety about their medical symptoms e. This change was made because there was little supporting evidence for the generalized specifier, and the evidence that SAD symptoms fall along a continuum of severity characterized by the number of fears [ ].
While the most up-to-date DSM-5 diagnostic criteria are presented here, it is important to note that all of the treatment data described within this section are based on patients meeting DSM-IV criteria or older. Psychological treatment, in the form of CBT, is considered to be the gold-standard nonpharmacological treatment in SAD.
Cognitive techniques involved in CBT for SAD include restructuring and challenging of maladaptive thoughts, while the behavioral component is typically in the form of exposure therapy. The efficacy of CBT compared with placebo, treatment-as-usual, or wait-list conditions, is supported by many RCTs as well as meta-analytic evidence [ 58 , 59 , 70 , 71 , ]. Although results vary, several studies of acute SAD treatment have also found a similar efficacy between CBT and pharmacotherapy [ — ].
Some reports suggest that after treatment discontinuation, gains achieved with CBT may persist longer than those achieved with pharmacotherapy [ , ]. Although some studies have reported that individual CBT is superior to group CBT [ , ], meta-analyses have failed to find significant differences in efficacy between the two modalities [ 58 , 59 , ]. The treatment literature has also examined the efficacy of the individual components of CBT. There is evidence to support the effectiveness of exposure therapy alone [ , ], however the efficacy of exposure alone compared with CBT is equivocal in the current treatment literature [ — ].
There are several variants of CBT that have been examined in the literature. For example, videotaped feedback was not shown to enhance the effects of exposure-based treatment [ ]. However, CBT with VRE was found to be more effective than wait-list control and as effective as CBT with imaginal or in vivo exposure according to two meta-analyses [ 80 , ]. A form of CBT focused on interpersonal behavior found similar improvements in social anxiety compared to standard CBT but also increased relationship satisfaction and social approach behaviors [ ].
Evidence to support interpersonal therapy IPT in SAD is conflicting [ — ]; while some results have been negative [ ], it is likely that IPT is more effective than wait-list control [ ], but less effective than traditional CBT [ , ]. In addition, small studies of attentional bias training suggest there may be some benefit associated with training patients to disengage from negative social cues, but data are conflicting [ , ]. Studies have evaluated this treatment in comparison to individual and group CBT. Most ICBT programs include minimal therapist contact via email [ — ] or telephone [ , ].
Effective Brief Therapies: A Clinician's Guide
Many programs involve a component of interaction with other participants through the use of internet discussion groups [ ]. However, it remains unclear whether the therapist component is necessary, and studies comparing guided with unguided ICBT have yielded conflicting results.
Similarly, a self-help program augmented with minimal therapist contact was more useful than a pure self-help strategy [ ].
A few ICBT programs included face-to-face in vivo exposure sessions [ , ], but one RCT found that adding this component did not significantly improve outcomes versus ICBT with self-directed exposure [ ]. As with other RCTs, research on ICBT has involved pre-screening of participants in-person or by telephone, with posttreatment and follow-up assessments by telephone or through self-report measures.
Little is known about the effectiveness of self-administered treatments ICBT or self-help books used with no pre-screening or planned follow-up contacts. When used in combination, pharmacotherapy has not been shown to add to the benefits of CBT in some studies [ , ], while one study found the combination of phenelzine and CBT superior to either modality alone [ ]. D-cycloserine has also been found to enhance treatment outcomes when used during exposure exercises as an adjunct to exposure alone [ , ].
In addition, a study of psychodynamic group therapy with or without the addition of clonazepam also found combination treatment to be superior to clonazepam treatment alone [ ]. The benefits of CBT have been found to be maintained at six to 12 month follow-up visits [ 58 , , , , , , , ], with sustained improvement being reported at five years posttreatment [ , ]. Long-term assessments post-ICBT have shown sustained improvement at one to five years follow-up [ , , , ].
Long-term benefits with psychotherapy appear to be more enduring than those of pharmacotherapy after treatment discontinuation [ , ]. The management of patients with SAD should follow the principles discussed in Section 2. Treatments that have been investigated for use in SAD have been assessed according to the criteria for strength of evidence Tables 1 and 2 and are summarized in Tables 20 and There is also good evidence for the efficacy of paroxetine CR Level 2 [ ].
Although there is Level 1 evidence for pregabalin, it is not clear how its efficacy compares to that of SSRIs. In addition, SSRIs may have a broader spectrum of efficacy for common comorbid conditions. Benzodiazepines: In RCTs, the benzodiazepines clonazepam Level 1 [ ][ , ], alprazolam [ ], and bromazepam [ ] both Level 2 have demonstrated efficacy in the treatment of SAD.
Antidepressants: In RCTs, citalopram was found to be significantly more effective than placebo [ ], and as effective as moclobemide [ ] Level 2. The efficacy of phenelzine has been established in multiple RCTs Level 1 [ , , , , ]; however, this agent is recommended as a second-line option because of concerns regarding dietary restrictions, drug interactions, and the potential for hypertensive crisis. Anticonvulsants: Gabapentin was significantly more effective than placebo in a RCT [ ], and as effective as tiagabine in a small cross-over study Level 2 [ ].
Antidepressants: Results with fluoxetine have been mixed Level 1, conflicting [ , , ]. However, in two other small RCTs, fluoxetine alone or when added to self-exposure showed no benefit over placebo, with or without self-exposure [ , ]. These negative trials with fluoxetine suggest it may be less effective than other SSRIs [ , ]. Similarly, results with moclobemide have also been mixed Level 1, conflicting [ , — ], with some RCTs demonstrating significantly higher response rates with moclobemide compared with placebo Level 1 [ — ], while others have not [ , ].
Moclobemide was found to be superior to CBT early in treatment; however, after six months CBT was found to be superior. Data from two small RCTs assessing mirtazapine were also mixed Level 1, conflicting , with one showing significant improvements over placebo [ ] and the other showing no differences [ ]. Small open-label trials have also suggested that bupropion SR [ ] and clomipramine [ , ] both Level 3 may be effective in patients with SAD. Anticonvulsants: Open-label studies have demonstrated some efficacy with divalproex [ ], topiramate [ ], and tiagabine [ ] all Level 3.
In addition, tiagabine was comparable to gabapentin in a small RCT, crossover study in eight adults [ ]. Other treatments: Olanzapine was effective in a small RCT Level 2 [ ], and selegiline demonstrated efficacy in a small, open-label trial Level 3 [ ]. In a RCT, atomoxetine significantly improved SAD symptoms compared with placebo [ ]; however, in a another small RCT, atomoxetine showed no significant difference in outcomes compared with placebo Level 1, conflicting [ ]. All of these agents are recommended as third-line options, and may be useful in refractory patients after first- and second-line monotherapies and adjuncts have been unsuccessful.
Adjunctive strategies have generally been studied in patients who have had an inadequate response to antidepressant therapy and can be considered for patients with treatment-resistant SAD. Third-line adjunctive therapies: Open-label studies and case series have suggested that patients with refractory SAD may benefit from adjunctive therapy with aripiprazole [ ], risperidone [ ], buspirone [ ], or paroxetine [ ] all Level 3. Not recommended adjunctive or combination therapies: In RCTs, clonazepam [ ] combined with paroxetine and pindolol augmentation of paroxetine [ ] both Level 2, negative were not significantly superior to placebo in augmenting the effects of SSRI treatment for SAD.
In RCTs there was no evidence of benefits with the beta-blockers atenolol Level 1, negative [ , ] or propranolol Level 2, negative [ ], or for the following treatments: buspirone [ , ], levetiracetam [ — ] both Level 1, negative , or quetiapine Level 2, negative [ , ]. These agents are not recommended for SAD. Imipramine [ ] and pergolide both Level 3, negative [ ] also do not appear to be effective in this disorder. Long-term therapy has been evaluated in relapse prevention and naturalistic follow-up studies. Relapse-prevention studies are those in which responders to medication are randomized to continued active treatment or placebo.
A meta-analysis of four relapse prevention studies included patients with SAD and found a highly significant reduction in relapse rates with continued SSRI treatment compared with placebo over three to six months. The relative risk RR for relapse was 0. The anticonvulsant pregabalin has also demonstrated reductions in relapse rates over six months [ ]. In RCTs, escitalopram [ ], fluvoxamine CR [ ], and venlafaxine XR [ ] have demonstrated continued improvement compared with placebo over approximately six months.
Additional open follow-up data support the long-term efficacy of moclobemide over six to 24 months [ , ]. SAD is one of the most common anxiety disorders, occurring more often in women than men. SAD has a negative impact on QoL, functional and occupational outcomes, and is often associated with other comorbid disorders, including MDD and other anxiety and related disorders.
SAD is characterized by intense fear or anxiety relating to social or performance situations where the individual is exposed to scrutiny by others. These situations are often actively avoided. CBT and exposure therapy alone are effective first-line options for the treatment of SAD, although limited data suggest that CBT may be more effective in maintaining benefits during follow-up.
VRE and internet-based programs have also demonstrated efficacy. The benefits of CBT are maintained over one to five years of follow-up. CBT and pharmacotherapy appear to have similar efficacy for the acute treatment of SAD, but after treatment discontinuation, gains achieved with CBT appear to persist longer than those achieved with pharmacotherapy. In most studies, adding pharmacotherapy has not been shown to increase the benefits of CBT. Pharmacotherapeutic approaches should begin with a first-line antidepressant such as escitalopram, fluvoxamine, fluvoxamine CR, paroxetine, paroxetine CR, sertraline, or venlafaxine XR, or the anticonvulsant pregabalin.
If response to optimal doses is inadequate or the agent is not tolerated, therapy should be switched to another first-line agent before considering a second-line medication. Second-line choices include the benzodiazepines alprazolam, bromazepam, and clonazepam, as well as citalopram, gabapentin, and phenelzine. Pregabalin has also been shown to maintain benefits and prevent relapse in a six-month study. In such patients it is important to reassess the diagnosis and consider comorbid medical and psychiatric conditions that may be affecting response to therapy.
Third-line agents and adjunctive therapies may be useful when patients fail to respond to optimal treatment trials of first- and second-line therapies used alone and in combination. GAD is more frequent in Caucasians compared to other groups [ ]. The usual age of onset varies and may be bimodal with the median age of onset being approximately 31 years [ 2 ] and mean age of onset being Some data suggest that women may be two to three times more likely to suffer from GAD than men [ 16 , ], and GAD may be more common in older adults [ , ]. This disorder is reportedly frequently under-recognized with less than one-third of patients being adequately treated [ , ].
This is further complicated in children because of the previous designation of Overanxious Disorder of Childhood and its possible differentiation of childhood GAD from GAD in adults. GAD is associated with functional [ 15 , , ], occupational [ ], and QoL impairments [ 16 , ], as well as substantial economic costs [ , ]. GAD is associated with high rates of comorbid psychiatric conditions including other anxiety or related disorders and MDD [ 16 ]. The risk of medical conditions is also elevated [ 16 ], including pain syndromes [ 16 , ], hypertension [ 16 ], as well as cardiovascular and gastric conditions [ 16 , ].
The presence of comorbid depression increases the severity of illness, functional impairment [ ], and economic costs [ ]. GAD is characterized by excessive anxiety and worry about multiple events or activities such as school or work difficulties, which is apparent on a majority of days over the previous six months Table 22 [ 26 ]. In addition, GAD is associated with restlessness, muscle tension, fatigue, concentration difficulties, irritability, and sleep issues [ 26 ]. The diagnostic criteria for GAD underwent one minor revision in the DSM-5 [ 26 ] compared to the DSM-IV-TR [ ], the requirement that the disturbance not occur exclusively during a mood, psychotic, or pervasive developmental disorder was removed.
However, it remains important to note that most of the treatment data described within this section are based on patients meeting DSM-IV criteria or older. Meta-analyses clearly demonstrate that CBT significantly reduces GAD symptoms and is markedly more effective than placebo or wait-list control conditions for GAD Level 1 [ 55 , 64 , 65 , 70 , ]. Few studies have compared CBT and pharmacotherapy alone in the same trial, but the magnitude of benefits appear to be comparable for both groups [ — ].
Individual and group therapy appear to be equally effective in terms of anxiety symptom reduction, but individual therapy may lead to earlier improvement in worry and depression symptoms [ 65 , ]. The intensity of therapy was assessed in a meta-analysis of 25 studies [ 65 ]. Regimens including fewer than eight sessions were as effective as those of eight or more for anxiety symptoms, but the more intense regimens were more effective in improving symptoms of worry and depression compared with fewer sessions [ 65 ].
Several studies have demonstrated the utility of internet-based or computer-based CBT programs [ 79 , — ]. ICBT has been shown to be significantly more effective than wait-list control [ 79 , , ], with benefits being maintained at long-term follow-up [ ]. In addition, a peer-to-peer cognitive self-therapy program was as effective as treatment-as-usual, with a decreased need for therapist contact [ ].
A meta-analysis of five trials found no significant differences between CBT and relaxation therapy [ 55 ]. However, more recent studies suggest that applied relaxation has limited efficacy [ — ]. One RCT found little evidence that patients with GAD can learn to relax in therapy or that a decrease in activation is associated with a reduction in anxiety [ ]. Balneotherapy, a relaxation therapy involving spa-related treatments, demonstrated potential advantages over SSRI pharmacotherapy in improving anxiety scores and response rates in patients with GAD in a large RCT [ ]; however, while this study may be interesting, concerns pertaining to blinding and potential bias indicate further study is needed [ ].
Several research-based variables have been specifically identified among individuals with GAD in order to generate evidence-based CBT protocols for GAD, including: intolerance of uncertainty, poor problem-solving confidence, as well as positive and negative metacognitive beliefs about the function or utility of worry [ ].
Specific psychotherapeutic protocols based upon models of the disorder that target variables underlying GAD have been developed to individualize therapy. Acceptance-based behavior therapy [ ], meta-cognitive therapy [ , ], CBT targeting intolerance of uncertainty [ ], and adjunctive MBCT [ ] have demonstrated efficacy for the treatment of GAD.
Targeting worry and relaxation [ ], as well as looming vulnerability the tendency to generate and maintain internal scenarios of increasing risk and danger [ ], may also be beneficial. Psychodynamic therapy may also be of benefit, however the research findings to date are unclear. A RCT found that short-term psychodynamic psychotherapy was as effective as CBT in improving anxiety scores, but CBT was superior on measures of worry and depression [ ].
Another study found no significant differences between brief psychodynamic therapy, pharmacotherapy, or the combination [ ]. No significant benefits were found with the addition of interpersonal and emotional processing therapy to CBT when compared with CBT plus supportive listening [ ].
However, pretreatment motivational interviewing as an adjunct to CBT was shown to help reduce resistance to therapy, improve homework compliance, and improve worry outcomes — this strategy may be particularly useful in more severe cases [ , ]. In clinical practice, the approach may need to be individualized to the problems experienced by the patient. Few data are available on the use of combined psychological and pharmacological treatment.
A meta-analysis concluded that combination pharmacotherapy and CBT was more effective than CBT alone at posttreatment but not at six-month follow-up [ 83 ].
Effective Brief Therapies: A Clinician's Guide by Michel Hersen, Maryka Biaggio - fodusulogi.tk
Compared to pharmacotherapy alone, the few studies that have assessed the benefits of adjunctive psychotherapy have been conflicting [ , , , ]. One study suggested benefits of the combination [ ], while two other studies did not [ , ]. There is no current evidence to support the routine combination of CBT and pharmacotherapy. However, as in other anxiety and related disorders, when patients do not benefit from CBT or have a limited response, a trial of pharmacotherapy is advisable. Long-term follow-up data from a meta-analysis [ ] and RCTs [ , , , ] suggest that benefits of psychological treatments are maintained at one to three years follow-up after treatment.
The management of patients with GAD should follow the principles discussed in Section 2. Treatments that have been investigated for use in GAD have been assessed according to the criteria for strength of evidence Tables 1 and 2 and are summarized in Tables 23 and Similar evidence exists for paroxetine [ , , — ] supporting its use as a first-line option. Paroxetine CR has a similar active ingredient, and although there are less data supporting its use, it is likely interchangeable with paroxetine as a first-line agent Level 3 [ , ].
Some data suggest that escitalopram may be less effective than venlafaxine XR [ ] or quetiapine XR [ ]. Efficacy of venlafaxine was similar to pregabalin in one RCT [ ], but less effective in another [ ]. Other antidepressants: In two week, double-blind RCTs, agomelatine was found to be more effective than placebo Level 1 [ , ], and as effective as escitalopram [ ]. Pregabalin: The anticonvulsant pregabalin was more effective than placebo in RCTs [ , , , , , ] and as effective as benzodiazepines [ , , ] in patients with GAD Level 1.
Pregabalin was more effective than venlafaxine XR in one RCT [ ], but equivalent in another [ ]. Benzodiazepines: Alprazolam [ — ], bromazepam [ , ], diazepam [ , , , ], and lorazepam [ , , — ] all have demonstrated efficacy for the treatment of GAD all Level 1. While these agents have level 1 evidence for efficacy, they are recommended as second-line therapy, and usually only for short-term use, because of side effects, dependence, and withdrawal issues.
However, because of side effects and potential toxicity in overdose, imipramine is recommended as a second-line option. While there are little data on bupropion XL Level 2 , in a week RCT in patients with GAD it was as effective as escitalopram a first-line option , supporting its use as a second-line option [ ]. Vortioxetine is a so-called "serotonin modulator" because of its activity in a variety of serotonin receptors. Results from two similar, eight-week, placebo-controlled RCTs with vortioxetine were conflicting, with one trial being positive [ ] and the other negative Level 1, conflicting [ ].
The differences in outcomes may be related to differences in recruitment between the two studies [ ], and data suggest that vortioxetine may be useful in GAD. Two meta-analyses [ , ] concluded that quetiapine was significantly superior to placebo and equivalent to antidepressants [ ] for the treatment of GAD.
However, quetiapine was associated with more weight gain and sedation, and higher dropout rates due to adverse events compared with placebo or antidepressants [ , ]. Due to tolerability and long-term safety concerns with atypical antipsychotics, this treatment is recommended as a second-line option for patients who cannot be provided antidepressants or benzodiazepines.
Other treatments: Buspirone was more effective than placebo and as effective as benzodiazepines in several RCTs Level 1 [ , , , , , , ]. There are limited data comparing buspirone to antidepressants, with it being less effective than venlafaxine XR in one study [ ], but as effective as sertraline in another [ ]. Limited effectiveness in clinical practice relegates buspirone to a second-line agent. Hydroxyzine has demonstrated efficacy superior to placebo and similar to benzodiazepines and buspirone in RCTs Level 1 [ , , ]; however, clinical experience with this agent in the treatment of GAD remains limited.
The following agents are recommended as third-line options because of limited data, side effects, or lack of clinical experience as a primary therapy for the treatment of GAD. Antidepressants: In open-label studies or case series, the antidepressants citalopram [ ], fluoxetine [ ], paroxetine CR [ , ], and mirtazapine [ ] have demonstrated efficacy in patients with GAD all Level 3. In a RCT, trazodone was as effective as diazepam Level 2 [ ]. Other treatments: Divalproex chrono was superior to placebo for the treatment of GAD Level 2 [ ], however this formulation is not widely available.
Adjunctive strategies have generally been studied in patients who have had an inadequate response to SSRI therapy, and can be considered for patients with treatment-resistant GAD. Second-line adjunctive therapies: Adjunctive pregabalin demonstrated good efficacy in a large RCT in patients with GAD who had an inadequate response to prior treatments Level 2 [ ]. Third-line adjunctive therapies: A meta-analysis of five RCTs of adjunctive atypical antipsychotics found no significant improvement in response rates but higher discontinuation rates versus placebo in patients with refractory GAD [ ].
Two RCTs suggest that adjunctive risperidone Level 1, conflicting [ , ] may be useful in some patients, but in the larger RCT it demonstrated superiority over placebo only in patients with moderate to severe residual symptoms at baseline [ ]. Similarly, data on adjunctive quetiapine have been inconsistent Level 1, conflicting [ , , ], with one RCT being negative [ ], while another, unblinded RCT showed some, but limited benefits [ ].
Adjunctive olanzapine demonstrated efficacy in a small RCT in patients who remained symptomatic after six weeks of SSRI therapy [ ]. Adjunctive treatment with quetiapine XR [ ] or aripiprazole [ , ] both Level 3 also had some benefit in open trials. Because of the limited evidence for efficacy and their potential for weight gain and metabolic side effects, atypical antipsychotics should be reserved for highly treatment-refractory cases of GAD, and other than quetiapine XR, used only as an adjunctive treatment.
Not recommended adjunctive therapies: Ziprasidone does not appear to be effective as adjunctive therapy Level 2, negative [ ]. Propranolol [ ] and pexacerfont [ ] both Level 2, negative have not demonstrated efficacy and are not recommended in the treatment of GAD. While a small randomized, open-label trial suggested that tiagabine was as effective as paroxetine, the results of three placebo-controlled RCTs do not support the efficacy of tiagabine in patients with GAD Level 1, negative [ , ].
Memantine also does not appear to be effective in this disorder Level 4, negative [ ]. Relapse-prevention studies are those in which responders to SSRI therapy are randomized to continued active treatment or placebo. A meta-analysis of three relapse prevention studies included patients with GAD and found a highly significant reduction in relapse rates with continued SSRI treatment compared with placebo over six to 12 months odds ratio for relapse was 0. Pregabalin [ ] and quetiapine XR [ ] have also demonstrated significantly lower relapse rates over six to 12 months of continued treatment in discontinuation trials.
In long-term RCT studies, escitalopram [ ], paroxetine [ ], and venlafaxine XR [ , ] have demonstrated continued improvement compared with placebo over approximately six months. Biological therapies: In a small open trial, rTMS was effective as monotherapy or as an adjunct to SSRIs in patients with GAD Level 3 [ ], and improvements were largely maintained six months after treatment [ ].
Alternative therapies: Several herbal preparations have demonstrated efficacy comparable to lorazepam for the treatment of GAD including silexan lavender oil Level 1 [ , ] and Galphimia glauca extract Level 2 [ ]. Cochrane meta-analyses found two studies of passiflora passion flower indicating it was as effective as benzodiazepines Level 2 [ ], and one study of valerian which found no significant differences between placebo, valerian, or diazepam Level 2, negative [ , ].
Unfortunately, because these preparations are poorly standardized and have substantial variation in proportion of the active ingredient in different products, they cannot be widely recommended. A RCT of adjunctive resistance training weightlifting or aerobic exercise found significant symptomatic improvements compared to a wait-list condition Level 2 [ ].
A systematic review included four studies of acupuncture in GAD or anxiety neurosis, and while all trials reported positive findings, methodological details were lacking and the authors concluded that there was insufficient evidence to determine efficacy Level 2 [ ]. Open-label studies suggest that adjunctive meditation and yoga-based treatments may be useful in patients with GAD Level 3 [ , ]. Not recommended alternative therapy: In a RCT, there were no significant improvements with bright light therapy compared with placebo Level 2, negative [ ], and this treatment is not recommended.
GAD is associated with substantial functional impairment and a high prevalence of comorbid psychiatric and medical disorders. According to DSM-5 criteria, GAD is characterized by excessive anxiety and worry about multiple situations and is associated with restlessness, muscle tension, and behavioral changes. CBT is an effective first-line option for the treatment of GAD and is as effective as pharmacotherapy. Internet-based and computer-based CBT have also demonstrated efficacy.
Evidence does not support the routine combination of CBT and pharmacotherapy, but when patients do not benefit from CBT, a trial of pharmacotherapy is advisable, and vice versa. Pharmacotherapeutic approaches should begin with one of the first-line options including an SSRI such as escitalopram, paroxetine, or sertraline, an SNRI such as duloxetine or venlafaxine XR, or other antidepressant such as agomelatine.
The anticonvulsant pregabalin is also a recommended first-line therapy. If response to optimal doses is inadequate or the agent is not tolerated, therapy should be switched to another first-line agent before considering second-line medications. Second-line choices include bupropion XL, buspirone, hydroxyzine, imipramine, quetiapine XR, vortioxetine, as well as the benzodiazepines, alprazolam, bromazepam, diazepam, and lorazepam. Patients who do not respond to multiple courses of therapy are considered to have treatment-refractory illness.
OCD is a relatively uncommon, yet severe, mental disorder, with an estimated lifetime and month prevalence of 1. Social isolation, history of physical abuse, and negative emotionality are risk factors for the development of OCD [ ]. OCD is associated with a substantial negative impact on QoL for both patients [ , ] and their caregivers [ ]. Patients experience cognitive, social, and occupational impairments [ , , , ]. In addition, up to one-quarter of patients with OCD have attempted suicide [ , ]. Common comorbidities include mood, anxiety, and somatoform disorders, as well as SUDs, psychotic disorders, and bipolar disorders [ , , ].
Obsessions are defined as recurrent, persistent, and intrusive thoughts, images, or urges that cause marked anxiety, and compulsions are defined as repetitive behaviors or mental acts that the patient feels compelled to perform to reduce the obsession-related anxiety [ 26 ]. The obsessions or compulsions are time consuming and cause significant impairment in social or occupational functioning. Most of the other modifications to the OCD diagnostic criteria in the DSM-5 were minor wording changes designed to enhance clarity or further operationalize concepts that were considered too vague [ 26 ].
In particular, the definitions of obsessions and compulsions were clarified and simplified [ 26 , ]. Finally, a specifier of "tic-related" OCD has been added [ 26 ]. Meta-analyses support the beneficial effects of psychological treatment for OCD, mainly CBT, generally including exposure with response prevention ERP [ 60 — 63 , 70 , 71 , — ]. CBT is equivalent or superior to pharmacotherapy [ 71 , — ]. Results with CBT were generally similar in comparisons of interventions with an emphasis on ERP and those with an emphasis on cognitive elements [ 60 , 63 , ]. Cognitive interventions may be important in patients who do not have overt compulsions, which can make ERP more difficult.
One meta-analysis found that exposure in vivo combined with imaginal exposure was better than exposure in vivo alone [ 60 ]. Several meta-analyses have demonstrated no significant differences in efficacy between group and individual CBT [ 60 , 62 , ]. However, results of head-to-head trials are conflicting, with some RCTs finding no significant differences in efficacy between group and individual therapy [ , ], and others showing individual therapy to be superior [ — ].
An important practical question concerns the intensity and duration of treatment. A step-care approach in which patients received six weeks of low-intensity counseling with ERP bibliotherapy followed by standard ERP for non-responders only was found to be as effective as initial therapy with standard ERP 17 sessions twice weekly , but was significantly less costly [ ].
Other techniques that may be useful include acceptance and commitment therapy ACT [ ], modular cognitive therapy CT addressing OCD beliefs [ , ], CT addressing obsessional doubt [ ], organizational training [ , ], and mindfulness training [ ].
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RCTs on the benefits of adding motivational interviewing to CBT have been conflicting, with one showing no additional benefits [ ], while another demonstrated improved symptom reduction and remission rates compared with CBT alone [ ]. Data suggest that therapist-guided exposure is better than self-exposure [ 60 ].
While both treatment conditions showed significant symptom reduction, therapist-administered ERP was superior to self-administered ERP in improving OCD symptoms and self-reported functional impairment [ ]. Bibliotherapy in the form of self-help manuals delivered to patients via email has demonstrated significantly greater improvements in OCD symptoms compared with wait-list control groups in two RCTs [ , ].
ICBT is an easily accessible treatment that has the potential to reach untreated patients and motivate them for face-to-face psychotherapy if necessary [ , ]. Several RCTs have demonstrated that ICBT programs are significantly more effective than supportive therapy or relaxation control strategies [ — ]. ICBT was associated with significantly better outcomes when it included brief, scheduled, therapist-initiated telephone support compared with on-demand phone support [ ].
Family accommodation i. Clinicians may want to consider targeting family accommodation in order to improve treatment outcomes for some patients. Although hoarding disorder is now a separate diagnosis [ ], the limited data available on the treatment of hoarding will be mentioned in this section on OCD. One RCT found that group CBT significantly reduced hoarding and depression symptoms while bibliotherapy alone was associated with very limited improvements [ ]. The addition of posttreatment, nonclinician, home assistance did not significantly improve outcomes.
The combination of psychological and pharmacological treatment has been shown to be superior to medication alone [ , , — ], but not to CBT alone [ 83 , , , , ]. These findings suggest that if pharmacotherapy is required or preferred, adding CBT to pharmacological treatment of OCD may enhance response rates and reduce relapse rates. Unlike in some anxiety and related disorders, there does not appear to be any contraindication to combining CBT with medications in patients with OCD [ ], and combined treatment may improve relapse prevention [ ].
Adding d-cycloserine may hasten the onset of improvements with ERP, with significant benefits over placebo during the first four or five ERP sessions [ — ], but this effect has not been seen in all studies [ ]. Follow-up studies suggest that the benefits of CBT are maintained at one to five years of follow-up [ , , — ]. The management of patients with OCD should follow the principles discussed in Section 2. Treatments that have been investigated for use in OCD have been assessed according to the criteria for strength of evidence Tables 1 and 2 and are summarized in Tables 26 and SSRIs: Evidence from RCTs and meta-analyses support the use of SSRIs, including escitalopram [ — ], fluoxetine [ , — ], fluvoxamine [ , , , — ], paroxetine [ , — ], and sertraline [ , , , , , — ] all Level 1 , in the treatment of OCD.
Pooled response rates are not significantly different between SSRIs [ ]. In meta-analyses and head-to-head trials, compared with clomipramine, the SSRIs fluoxetine, fluvoxamine, paroxetine, and sertraline had similar efficacy but better tolerability [ , , , — , , ]. Clomipramine: There is good evidence to support the use of clomipramine in the treatment of OCD Level 1 [ , , , , — , , , , ]. Side effects and safety are issues with clomipramine and therefore it is recommended as a second-line choice.
Common adverse effects include anticholinergic effects such as dry mouth, constipation, and blurred vision, as well as urinary retention, orthostatic hypotension, weight gain, and sedation [ , ]. The major safety concerns are cardiac arrhythmias, seizures, drug interactions, and toxicity in overdose [ , ]. Antidepressants: In RCTs, citalopram was more effective than placebo but less effective than psychotherapy Level 2 [ , ]. Additional data from augmentation studies support the efficacy of citalopram for the treatment of OCD [ , ]. However, given that other SSRIs have much stronger evidence, citalopram was designated a second-line option.
The only RCT data on the use of mirtazapine in OCD are from a discontinuation study in which continued mirtazapine was associated with continued improvement Level 2 [ ]. In RCTs, venlafaxine XR was more effective than placebo [ ], and as effective as paroxetine [ ] and clomipramine [ ]. In a double-blind extension of a RCT [ ], paroxetine was more efficacious than venlafaxine in the treatment of non-responders to previous treatment with the alternate antidepressant [ ].
Initiating therapy with IV then switching to oral therapy does not appear to be associated with greater benefit compared with oral therapy alone [ , ]. Other agents: IV citalopram [ ] Level 3 , as well as duloxetine [ — ], tramadol [ , ], and tranylcypromine [ ] all Level 4 have demonstrated some efficacy in open trials or case reports. Results with phenelzine have been inconsistent.
In one RCT, phenelzine was not significantly better than placebo [ ], but in another it was as effective as clomipramine Level 2 [ ]. In the placebo-controlled trial, post-hoc analysis suggested that phenelzine may be beneficial in patients with symmetry or other atypical obsessions [ ]. These agents are recommended as third-line options, and may be useful in refractory patients after first- and second-line monotherapies and adjuncts have been unsuccessful.
Adjunctive strategies have generally been studied in patients who have had an inadequate response to SSRI therapy, and can be considered for patients with treatment-resistant OCD. A meta-analysis demonstrated that response rates with adjunctive medication were twice those of placebo, however these were still quite low Meta-analyses of RCTs found that adding risperidone and possibly quetiapine to antidepressants increased efficacy but decreased tolerability, while adjunctive olanzapine did not improve response rates [ , ].
First-line adjunctive therapies: In RCTs, adjunctive aripiprazole was significantly more effective than placebo Level 1 [ , ], and may be as effective as risperidone [ ].
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Additional open-label data also support the beneficial effects of adjunctive aripiprazole [ — ]. As adjunctive therapy for treatment-resistant OCD, risperidone was more effective than placebo Level 1 [ — ] and as effective as olanzapine [ ] and aripiprazole overall [ ]. Compared with aripiprazole, risperidone may provide greater improvement in obsessions [ ]. Risperidone was also as effective as haloperidol for obsessions, but less so for compulsions, however it was better tolerated [ ].
More recently an open, randomized study found that while augmentation with ERP was superior to risperidone or pill placebo, risperidone was not significantly more effective than placebo [ ]. However, patients in this study had some response to SSRI therapy and may have been less refractory compared to those in other studies. Considering the tolerability concerns of atypical antipsychotics, these data reinforce that this augmentation strategy should be reserved for patients with treatment-resistant OCD.
Second-line adjunctive therapies: RCT evidence demonstrated that adjunctive memantine was superior to placebo Level 2 [ ]. Additional open-label data also support this therapy [ , , ]. Another option which may be useful as an adjunctive therapy in those with refractory OCD is the atypical antipsychotic quetiapine Level 1, conflicting [ , , , — , ].
Data from small RCTs suggest that topiramate may be a useful adjunctive therapy, but data are conflicting Level 1 [ , ]. In one RCT, adjunctive topiramate significantly improved Yale-Brown Obsessive Compulsive Scale Y-BOCS scores compared with placebo [ ], while in another trial, adjunctive topiramate significantly improved compulsions but not obsessions [ ]. Additional open-label data support the use of adjunctive topiramate [ , ]. Third-line adjunctive therapies: The agents discussed below are recommended as third-line adjunctive options, since some data are available to suggest they may be useful but there is conflicting or inadequate evidence to warrant stronger recommendations.
These agents may be useful for some patients, but more data are needed. Other atypical antipsychotics have been assessed as adjunctive therapies in patients with refractory OCD, including olanzapine Level 1, conflicting [ , , ], amisulpride Level 3 [ ], and ziprasidone Level 4 [ ]. There is level 2 evidence to support the use of adjunctive haloperidol in patients with refractory OCD [ , ], and although it may be as effective as adjunctive risperidone, it is a third-line choice because it was less well tolerated [ ].
Adjunctive mirtazapine was associated with an earlier onset of response of OCD symptoms compared with citalopram alone, but there was no advantage of the combination over time Level 2 [ ]. Some data also support the efficacy of adjunctive citalopram for treatment-resistant OCD Level 3 [ ]. Adjunctive anticonvulsants may be useful for some patients with refractory illness [ — ].
Open-label data also suggest that adjunctive pregabalin may be useful Level 3 [ , ]. Other agents that have been studied as adjunctive therapy for treatment-resistant OCD include celecoxib [ ], granisetron [ ], IV ketamine [ , ], ondansetron [ , ], N-acetylcysteine [ , ] all Level 2 , and riluzole Level 3 [ , ]. There is little clinical experience with these agents for refractory OCD, therefore they are recommended as third-line adjunctive options only. Results with pindolol augmentation have been inconsistent, with significant improvements in one small RCT [ ], but not in other randomized or open trials Level 1, conflicting [ , ].
In two randomized, quetiapine-controlled trials, adjunctive clomipramine was not superior to SSRI therapy Level 2, negative [ , ]. Clinical experience suggests that some patients may benefit from adjunctive clomipramine; however, plasma levels should be monitored because of the risk of drug interactions with SSRIs [ , ]. Clonazepam [ ], clonidine [ ], and desipramine all Level 2, negative [ , ] have not demonstrated efficacy and are not recommended in the treatment of OCD. Bupropion [ ] and naltrexone both Level 3, negative [ ] also do not appear to be effective in this disorder.
Adjunctive buspirone [ , ], clonazepam [ ] Level 2, negative , or lithium [ , ] Level 1, negative have not demonstrated efficacy for the treatment of OCD. There is currently no evidence for the efficacy of adjunctive gabapentin Level 3, negative [ , ] or minocycline Level 4, negative [ ], but there are insufficient data to make recommendations at this time.
In a RCT, adjunctive once-weekly oral morphine was effective in patients who had failed six SSRI trials Level 2 [ ], however, morphine is not generally recommended because of its potential for abuse. A meta-analysis of six relapse prevention studies included patients with OCD and found a highly significant reduction in relapse rates with continued SSRI treatment compared with placebo over six to 12 months odds ratio for relapse was 0. In RCTs, escitalopram [ ], paroxetine [ ], sertraline [ ], and high-dose fluoxetine [ ] have demonstrated reductions in relapse rates.
In RCT discontinuation studies, mirtazapine [ ] and clomipramine [ ] have demonstrated continued improvement compared with placebo over approximately six to 12 months. Additional data support the long-term efficacy of fluoxetine, fluvoxamine XR, and sertraline over six to 24 months [ , — ]. Biological therapies: Biological therapies may be useful in patients with OCD who have not responded to CBT and multiple medication trials. Open trials have suggested that rTMS may be a promising adjunctive therapy in patients with treatment-refractory OCD [ , ]. However, results of sham-controlled trials are conflicting, with some trials finding significant improvements [ , ] and others concluding that rTMS was ineffective for treatment-resistant OCD Level 1, conflicting [ — ].
Several very small studies have suggested that deep brain stimulation may improve symptoms and functionality in up to two-thirds of patients with highly treatment-refractory OCD Level 4 [ — ]. Open trials suggest that capsulotomy Level 3 [ — ] or cingulotomy Level 3 [ — ] may be effective in reducing symptoms in patients with severe, treatment-refractory OCD, however these treatments are usually considered last resorts.
Alternative therapies: A meta-analysis of meditation therapies found only two small studies and showed that transcendental meditation and Kundalini yoga were likely no more effective than other kinds of relaxation therapies in treating OCD Level 3, negative [ ]. Open studies suggest that adjunctive moderate-intensity aerobic exercise may help improve OCD symptoms Level 3 [ , ]. Small RCTs and open trials have suggested that herbal therapies such as milk thistle Silybum marianum L.
Level 2 [ ], valerian root Valeriana officinalis L. Unfortunately, because these preparations are poorly standardized and have substantial variation in the proportion of the active ingredient in different products, they cannot be widely recommended. OCD is a relatively rare, yet severe, mental disorder, with an onset in the 20s or earlier.
OCD is associated with substantial functional impairment and a high prevalence of comorbid disorders. CBT can be effectively delivered in both individual and group settings, as well as via self-exposure, self-help books, telephone, and internet-based programs. The combination of psychotherapy and pharmacotherapy appears to be superior to pharmacotherapy alone, but not to CBT alone, and data suggest that adding CBT to pharmacological treatment may yield better long-term outcomes.
Pharmacotherapeutic approaches should begin with a first-line SSRI such as escitalopram, fluoxetine, fluvoxamine, paroxetine, or sertraline. Second-line choices include citalopram, clomipramine, mirtazapine, and venlafaxine XR. OCD can be difficult to treat; therefore, in order to preserve any benefits of a therapy, adjunctive strategies may be important early in treatment.
Third-line agents, adjunctive therapies, as well as biological and alternative therapies may be useful when patients fail to respond to optimal treatment trials of first- and second-line therapies used alone and in combination. US and European community studies report lifetime prevalence rates of 6. The most common forms of trauma resulting in PTSD included unexpected death of someone close, sexual assault, serious illness or injury to someone close, having a child with serious illness, and being beaten by a partner or caregiver [ — ].
Onset is generally in the mid to late 20s [ 2 ], and the prevalence is about twice as high among women versus men [ , ]. PTSD was associated with significant QoL [ ] and functional impairments [ , — ], which increase with increasing severity of symptoms [ ]. In addition, PTSD is associated with high rates of chronic pain [ — ], sleep problems [ ], and sexual dysfunction [ ], as well as cognitive dysfunction [ , ] and alexithymia [ ]. The risk of suicide attempts is increased two- to three-fold by the presence of PTSD [ 20 , , ].
In primary care, PTSD was associated with more and longer hospitalizations as well as a greater use of mental health care [ ]. Among Canadian military personnel, greater use of mental health care was associated with cumulative lifetime trauma exposure, index trauma type, PTSD symptom interference, suicidal ideation, female gender, and comorbid MDD [ , ].
go to link Comorbid panic or mood disorders have been associated with greater functional impairment than PTSD alone [ , ]. Patients with comorbid PTSD and BPD had a poorer QoL, more comorbidity with other psychiatric conditions, and increased odds of a lifetime suicide attempt versus patients with either condition alone [ 20 , ]. By definition PTSD requires exposure to trauma, including actual or threatened death, serious injury, or sexual violation [ 26 ]. It is characterized by intrusive and distressing memories or dreams, dissociative reactions, and substantial psychological or physiological distress related to the event Table 28 [ 26 ].
In addition to PTSD, this new category also includes diagnostic criteria for reactive attachment disorder, disinhibited social engagement disorder, ASD, and adjustment disorders [ 26 ]. While the most up-to-date DSM-5 diagnostic criteria are being presented here, it is important to note that the treatment data described within this section are based on patients meeting DSM-IV criteria or older.
PTSD is frequently comorbid with other psychiatric disorders, including other anxiety and related disorders, MDD, and SUDs, which may complicate diagnosis and management [ , ]. In addition, patients with PTSD frequently present with somatic symptoms and pain [ ]. It is important to ask patients with psychological or somatic symptoms about trauma [ 32 , ]. A number of studies have assessed early intervention with psychological and pharmacological strategies for the prevention of PTSD.
Recommended for: people trying to learn more about treatment. Very descriptive with case examples and thorough investigation on what treatments may work best. However, I felt there was not much in the way of experimental treatment - it seems to only talk about CBT most of the time, which isn't the only therapy out there.
Also, they did not touch on many common MI problems as they could have. Useful for class, but I feel the reader should explore other options of treatment before committing to what this Holy Book says. Sign into Goodreads to see if any of your friends have read Effective Brief Therapies. Reading Progress. June 20, — Shelved as: educational. June 20, — Shelved as: for-school.
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