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Avoidance Predicts Worse Long-term Outcomes From Intensive OCD Treatment
BOSTON — , a new analysis shows.
Although avoidant patients with OCD reported symptom improvement immediately after treatment, baseline avoidance was associated with significantly worse outcomes 1 year later.
“Avoidance is often overlooked in OCD,” said lead investigator Michael Wheaton, PhD, an assistant professor of psychology at Barnard College in New York. “It’s really important clinically to focus on that.”
The findings were presented at the Anxiety and Depression Association of America (ADAA) annual conference and published online in the Journal of Obsessive-Compulsive and Related Disorders.
The Avoidance Question
Although ERP is often included in treatment for OCD, between 38% and 60% of patients have residual symptoms after treatment and as many as a quarter don’t respond at all, Dr. Wheaton said.
Severe pretreatment avoidance could affect the efficacy of ERP, which involves exposing patients to situations and stimuli they may usually avoid. But prior research to identify predictors of ERP outcomes have largely excluded severity of pretreatment avoidance as a factor.
The new study analyzed data from 161 Norwegian adults with treatment-resistant OCD who participated in a concentrated ERP therapy called the Bergen 4-day Exposure and Response Prevention (B4DT) treatment. This method delivers intensive treatment over 4 consecutive days in small groups with a 1:1 ratio of therapists to patients.
B4DT is common throughout Norway, with the treatment offered at 55 clinics, and has been trialed in other countries including the United States, Nepal, Ecuador, and Kenya.
Symptom severity was measured using the Yale-Brown Obsessive Compulsive Scale (YBOCS) at baseline, immediately after treatment, and 3 and 12 months later. Functional impairment was measured 12 months after treatment using the Work and Social Adjustment Scale.
Although the formal scoring of the YBOCS does not include any questions about avoidance, one question in the auxiliary items does: “Have you been avoiding doing anything, going anyplace or being with anyone because of obsessional thoughts or out of a need to perform compulsions?”
Dr. Wheaton used this response, which is rated on a five-point scale, to measure avoidance. Overall, 18.8% of participants had no deliberate avoidance, 15% were rated as having mild avoidance, 36% moderate, 23% severe, and 6.8% extreme.
Long-Term Outcomes
Overall, 84% of participants responded to treatment, with a change in mean YBOCS scores from 26.98 at baseline to 12.28 immediately after treatment. Acute outcomes were similar between avoidant and nonavoidant patients.
But at 12-month follow-up, even after controlling for pretreatment OCD severity, patients with more extensive avoidance at baseline had worse long-term outcomes — both more severe OCD symptoms (P = .031) and greater functional impairment (P = .002).
Across all patients, average avoidance decreased significantly immediately after the concentrated ERP treatment. Average avoidance increased somewhat at 3- and 12-month follow-up but remained significantly improved from pretreatment.
Interestingly, patients’ change in avoidance immediately post-treatment to 3 months post-treatment predicted worsening of OCD severity at 12 months. This change could potentially identify people at risk of relapse, Dr. Wheaton said.
Previous research has shown that pretreatment OCD severity, measured using the YBOCS, does not significantly predict ERP outcomes, and this study found the same.
Relapse Prevention
“The fact that they did equally well in the short run I think was great,” Dr. Wheaton said.
Previous research, including 2018 and 2023 papers from Wheaton’s team, has shown that more avoidant patients have worse outcomes from standard 12-week ERP programs.
One possible explanation for this difference is that in the Bergen treatment, most exposures happen during face-to-face time with a therapist instead of as homework, which may be easier to avoid, he said.
“But then the finding was that their symptoms were worsening over time — their avoidance was sliding back into old habits,” said Dr. Wheaton.
He would like to see the study replicated in diverse populations outside Norway and in treatment-naive people. Dr. Wheaton also noted that the study assessed avoidance with only a single item.
Future work is needed to test ways to improve relapse prevention. For example, clinicians may be able to monitor for avoidance behaviors post-treatment, which could be the start of a relapse, said Dr. Wheaton.
Although clinicians consider avoidance when treating phobias, social anxiety disorder, and panic disorder, “somehow avoidance got relegated to item 11 on the YBOCS that isn’t scored,” Helen Blair Simpson, MD, PhD, director of the Center for OCD and Related Disorders at Columbia University, New York, New York, said during the presentation.
A direct implication of Dr. Wheaton’s findings to clinical practice is to “talk to people about their avoidance right up front,” said Dr. Simpson, who was not part of the study.
Clinicians who deliver ERP in their practices “can apply this tomorrow,” Dr. Simpson added.
Dr. Wheaton reported no disclosures. Dr. Simpson reported a stipend from the American Medical Association for serving as associate editor of JAMA Psychiatry and royalties from UpToDate, Inc for articles on OCD and from Cambridge University Press for editing a book on anxiety disorders.
A version of this article appeared on Medscape.com.
BOSTON — , a new analysis shows.
Although avoidant patients with OCD reported symptom improvement immediately after treatment, baseline avoidance was associated with significantly worse outcomes 1 year later.
“Avoidance is often overlooked in OCD,” said lead investigator Michael Wheaton, PhD, an assistant professor of psychology at Barnard College in New York. “It’s really important clinically to focus on that.”
The findings were presented at the Anxiety and Depression Association of America (ADAA) annual conference and published online in the Journal of Obsessive-Compulsive and Related Disorders.
The Avoidance Question
Although ERP is often included in treatment for OCD, between 38% and 60% of patients have residual symptoms after treatment and as many as a quarter don’t respond at all, Dr. Wheaton said.
Severe pretreatment avoidance could affect the efficacy of ERP, which involves exposing patients to situations and stimuli they may usually avoid. But prior research to identify predictors of ERP outcomes have largely excluded severity of pretreatment avoidance as a factor.
The new study analyzed data from 161 Norwegian adults with treatment-resistant OCD who participated in a concentrated ERP therapy called the Bergen 4-day Exposure and Response Prevention (B4DT) treatment. This method delivers intensive treatment over 4 consecutive days in small groups with a 1:1 ratio of therapists to patients.
B4DT is common throughout Norway, with the treatment offered at 55 clinics, and has been trialed in other countries including the United States, Nepal, Ecuador, and Kenya.
Symptom severity was measured using the Yale-Brown Obsessive Compulsive Scale (YBOCS) at baseline, immediately after treatment, and 3 and 12 months later. Functional impairment was measured 12 months after treatment using the Work and Social Adjustment Scale.
Although the formal scoring of the YBOCS does not include any questions about avoidance, one question in the auxiliary items does: “Have you been avoiding doing anything, going anyplace or being with anyone because of obsessional thoughts or out of a need to perform compulsions?”
Dr. Wheaton used this response, which is rated on a five-point scale, to measure avoidance. Overall, 18.8% of participants had no deliberate avoidance, 15% were rated as having mild avoidance, 36% moderate, 23% severe, and 6.8% extreme.
Long-Term Outcomes
Overall, 84% of participants responded to treatment, with a change in mean YBOCS scores from 26.98 at baseline to 12.28 immediately after treatment. Acute outcomes were similar between avoidant and nonavoidant patients.
But at 12-month follow-up, even after controlling for pretreatment OCD severity, patients with more extensive avoidance at baseline had worse long-term outcomes — both more severe OCD symptoms (P = .031) and greater functional impairment (P = .002).
Across all patients, average avoidance decreased significantly immediately after the concentrated ERP treatment. Average avoidance increased somewhat at 3- and 12-month follow-up but remained significantly improved from pretreatment.
Interestingly, patients’ change in avoidance immediately post-treatment to 3 months post-treatment predicted worsening of OCD severity at 12 months. This change could potentially identify people at risk of relapse, Dr. Wheaton said.
Previous research has shown that pretreatment OCD severity, measured using the YBOCS, does not significantly predict ERP outcomes, and this study found the same.
Relapse Prevention
“The fact that they did equally well in the short run I think was great,” Dr. Wheaton said.
Previous research, including 2018 and 2023 papers from Wheaton’s team, has shown that more avoidant patients have worse outcomes from standard 12-week ERP programs.
One possible explanation for this difference is that in the Bergen treatment, most exposures happen during face-to-face time with a therapist instead of as homework, which may be easier to avoid, he said.
“But then the finding was that their symptoms were worsening over time — their avoidance was sliding back into old habits,” said Dr. Wheaton.
He would like to see the study replicated in diverse populations outside Norway and in treatment-naive people. Dr. Wheaton also noted that the study assessed avoidance with only a single item.
Future work is needed to test ways to improve relapse prevention. For example, clinicians may be able to monitor for avoidance behaviors post-treatment, which could be the start of a relapse, said Dr. Wheaton.
Although clinicians consider avoidance when treating phobias, social anxiety disorder, and panic disorder, “somehow avoidance got relegated to item 11 on the YBOCS that isn’t scored,” Helen Blair Simpson, MD, PhD, director of the Center for OCD and Related Disorders at Columbia University, New York, New York, said during the presentation.
A direct implication of Dr. Wheaton’s findings to clinical practice is to “talk to people about their avoidance right up front,” said Dr. Simpson, who was not part of the study.
Clinicians who deliver ERP in their practices “can apply this tomorrow,” Dr. Simpson added.
Dr. Wheaton reported no disclosures. Dr. Simpson reported a stipend from the American Medical Association for serving as associate editor of JAMA Psychiatry and royalties from UpToDate, Inc for articles on OCD and from Cambridge University Press for editing a book on anxiety disorders.
A version of this article appeared on Medscape.com.
BOSTON — , a new analysis shows.
Although avoidant patients with OCD reported symptom improvement immediately after treatment, baseline avoidance was associated with significantly worse outcomes 1 year later.
“Avoidance is often overlooked in OCD,” said lead investigator Michael Wheaton, PhD, an assistant professor of psychology at Barnard College in New York. “It’s really important clinically to focus on that.”
The findings were presented at the Anxiety and Depression Association of America (ADAA) annual conference and published online in the Journal of Obsessive-Compulsive and Related Disorders.
The Avoidance Question
Although ERP is often included in treatment for OCD, between 38% and 60% of patients have residual symptoms after treatment and as many as a quarter don’t respond at all, Dr. Wheaton said.
Severe pretreatment avoidance could affect the efficacy of ERP, which involves exposing patients to situations and stimuli they may usually avoid. But prior research to identify predictors of ERP outcomes have largely excluded severity of pretreatment avoidance as a factor.
The new study analyzed data from 161 Norwegian adults with treatment-resistant OCD who participated in a concentrated ERP therapy called the Bergen 4-day Exposure and Response Prevention (B4DT) treatment. This method delivers intensive treatment over 4 consecutive days in small groups with a 1:1 ratio of therapists to patients.
B4DT is common throughout Norway, with the treatment offered at 55 clinics, and has been trialed in other countries including the United States, Nepal, Ecuador, and Kenya.
Symptom severity was measured using the Yale-Brown Obsessive Compulsive Scale (YBOCS) at baseline, immediately after treatment, and 3 and 12 months later. Functional impairment was measured 12 months after treatment using the Work and Social Adjustment Scale.
Although the formal scoring of the YBOCS does not include any questions about avoidance, one question in the auxiliary items does: “Have you been avoiding doing anything, going anyplace or being with anyone because of obsessional thoughts or out of a need to perform compulsions?”
Dr. Wheaton used this response, which is rated on a five-point scale, to measure avoidance. Overall, 18.8% of participants had no deliberate avoidance, 15% were rated as having mild avoidance, 36% moderate, 23% severe, and 6.8% extreme.
Long-Term Outcomes
Overall, 84% of participants responded to treatment, with a change in mean YBOCS scores from 26.98 at baseline to 12.28 immediately after treatment. Acute outcomes were similar between avoidant and nonavoidant patients.
But at 12-month follow-up, even after controlling for pretreatment OCD severity, patients with more extensive avoidance at baseline had worse long-term outcomes — both more severe OCD symptoms (P = .031) and greater functional impairment (P = .002).
Across all patients, average avoidance decreased significantly immediately after the concentrated ERP treatment. Average avoidance increased somewhat at 3- and 12-month follow-up but remained significantly improved from pretreatment.
Interestingly, patients’ change in avoidance immediately post-treatment to 3 months post-treatment predicted worsening of OCD severity at 12 months. This change could potentially identify people at risk of relapse, Dr. Wheaton said.
Previous research has shown that pretreatment OCD severity, measured using the YBOCS, does not significantly predict ERP outcomes, and this study found the same.
Relapse Prevention
“The fact that they did equally well in the short run I think was great,” Dr. Wheaton said.
Previous research, including 2018 and 2023 papers from Wheaton’s team, has shown that more avoidant patients have worse outcomes from standard 12-week ERP programs.
One possible explanation for this difference is that in the Bergen treatment, most exposures happen during face-to-face time with a therapist instead of as homework, which may be easier to avoid, he said.
“But then the finding was that their symptoms were worsening over time — their avoidance was sliding back into old habits,” said Dr. Wheaton.
He would like to see the study replicated in diverse populations outside Norway and in treatment-naive people. Dr. Wheaton also noted that the study assessed avoidance with only a single item.
Future work is needed to test ways to improve relapse prevention. For example, clinicians may be able to monitor for avoidance behaviors post-treatment, which could be the start of a relapse, said Dr. Wheaton.
Although clinicians consider avoidance when treating phobias, social anxiety disorder, and panic disorder, “somehow avoidance got relegated to item 11 on the YBOCS that isn’t scored,” Helen Blair Simpson, MD, PhD, director of the Center for OCD and Related Disorders at Columbia University, New York, New York, said during the presentation.
A direct implication of Dr. Wheaton’s findings to clinical practice is to “talk to people about their avoidance right up front,” said Dr. Simpson, who was not part of the study.
Clinicians who deliver ERP in their practices “can apply this tomorrow,” Dr. Simpson added.
Dr. Wheaton reported no disclosures. Dr. Simpson reported a stipend from the American Medical Association for serving as associate editor of JAMA Psychiatry and royalties from UpToDate, Inc for articles on OCD and from Cambridge University Press for editing a book on anxiety disorders.
A version of this article appeared on Medscape.com.
FROM ADAA 2024
Nontraditional Risk Factors Play an Outsized Role in Young Adult Stroke Risk
, new research showed.
The findings may offer insight into the increased incidence of stroke in adults under age 45, which has more than doubled in the past 20 years in high-income countries, while incidence in those over 45 has decreased.
Investigators believe the findings are important because most conventional prevention efforts focus on traditional risk factors.
“The younger they are at the time of stroke, the more likely their stroke is due to a nontraditional risk factor,” lead author Michelle Leppert, MD, an assistant professor of neurology at the University of Colorado School of Medicine, Aurora, Colorado, said in a news release.
The findings were published online in Circulation: Cardiovascular Quality and Outcomes.
Traditional Versus Nontraditional
The researchers retrospectively analyzed 2618 stroke cases (52% female; 73% ischemic stroke) that resulted in an inpatient admission and 7827 controls, all aged 18-55 years. Data came from the Colorado All Payer Claims Database between January 2012 and April 2019. Controls were matched by age, sex, and insurance type.
Traditional risk factors were defined as being a well-established risk factor for stroke that is routinely noted during stroke prevention screenings in older adults, including hypertension, diabetes, hyperlipidemia, sleep apnea, cardiovascular disease, alcohol, substance use disorder, and obesity.
Nontraditional risk factors were defined as those that are rarely cited as a cause of stroke in older adults, including migraines, malignancy, HIV, hepatitis, thrombophilia, autoimmune disease, vasculitis, sickle cell disease, heart valve disease, renal failure, and hormonal risk factors in women, such as oral contraceptives, pregnancy, or puerperium.
Overall, traditional risk factors were more common in stroke cases, with nontraditional factors playing a smaller role. However, among adults aged 18-34 years, more strokes were associated with nontraditional than traditional risk factors in men (31% vs 25%, respectively) and in women (43% vs 33%, respectively).
Migraine, the most common nontraditional risk factor for stroke in this younger age group, was found in 20% of men (odds ratio [OR], 3.9) and 35% of women (OR, 3.3).
Other notable nontraditional risk factors included heart valve disease in both men and women (OR, 3.1 and OR, 4.2, respectively); renal failure in men (OR, 8.9); and autoimmune diseases in women (OR, 8.8).
An Underestimate?
The contribution of nontraditional risk factors declined with age. After the age of 44, they were no longer significant. Hypertension was the most important traditional risk factor and increased in contribution with age.
“There have been many studies demonstrating the association between migraines and strokes, but to our knowledge, this study may be the first to demonstrate just how much stroke risk may be attributable to migraines,” Dr. Leppert said.
Overall, women had significantly more risk factors for stroke than men. Among controls, 52% and 34% of women had at least one traditional and nontraditional risk factors, respectively, compared with 48% and 22% in men.
The total contribution of nontraditional risk factors was likely an underestimate because some such factors, including the autoimmune disorder antiphospholipid syndrome and patent foramen ovale, “lacked reliable administrative algorithms” and could not be assessed in this study, the researchers noted.
Further research on how nontraditional risk factors affect strokes could lead to better prevention.
“We need to better understand the underlying mechanisms of these nontraditional risk factors to develop targeted interventions,” Dr. Leppert said.
The study was funded by the National Institutes of Health/National Center for Advancing Translational Sciences Colorado Clinical and Translational Science Award. Dr. Leppert reports receiving an American Heart Association Career Development Grant. Other disclosures are included in the original article.
A version of this article appeared on Medscape.com.
, new research showed.
The findings may offer insight into the increased incidence of stroke in adults under age 45, which has more than doubled in the past 20 years in high-income countries, while incidence in those over 45 has decreased.
Investigators believe the findings are important because most conventional prevention efforts focus on traditional risk factors.
“The younger they are at the time of stroke, the more likely their stroke is due to a nontraditional risk factor,” lead author Michelle Leppert, MD, an assistant professor of neurology at the University of Colorado School of Medicine, Aurora, Colorado, said in a news release.
The findings were published online in Circulation: Cardiovascular Quality and Outcomes.
Traditional Versus Nontraditional
The researchers retrospectively analyzed 2618 stroke cases (52% female; 73% ischemic stroke) that resulted in an inpatient admission and 7827 controls, all aged 18-55 years. Data came from the Colorado All Payer Claims Database between January 2012 and April 2019. Controls were matched by age, sex, and insurance type.
Traditional risk factors were defined as being a well-established risk factor for stroke that is routinely noted during stroke prevention screenings in older adults, including hypertension, diabetes, hyperlipidemia, sleep apnea, cardiovascular disease, alcohol, substance use disorder, and obesity.
Nontraditional risk factors were defined as those that are rarely cited as a cause of stroke in older adults, including migraines, malignancy, HIV, hepatitis, thrombophilia, autoimmune disease, vasculitis, sickle cell disease, heart valve disease, renal failure, and hormonal risk factors in women, such as oral contraceptives, pregnancy, or puerperium.
Overall, traditional risk factors were more common in stroke cases, with nontraditional factors playing a smaller role. However, among adults aged 18-34 years, more strokes were associated with nontraditional than traditional risk factors in men (31% vs 25%, respectively) and in women (43% vs 33%, respectively).
Migraine, the most common nontraditional risk factor for stroke in this younger age group, was found in 20% of men (odds ratio [OR], 3.9) and 35% of women (OR, 3.3).
Other notable nontraditional risk factors included heart valve disease in both men and women (OR, 3.1 and OR, 4.2, respectively); renal failure in men (OR, 8.9); and autoimmune diseases in women (OR, 8.8).
An Underestimate?
The contribution of nontraditional risk factors declined with age. After the age of 44, they were no longer significant. Hypertension was the most important traditional risk factor and increased in contribution with age.
“There have been many studies demonstrating the association between migraines and strokes, but to our knowledge, this study may be the first to demonstrate just how much stroke risk may be attributable to migraines,” Dr. Leppert said.
Overall, women had significantly more risk factors for stroke than men. Among controls, 52% and 34% of women had at least one traditional and nontraditional risk factors, respectively, compared with 48% and 22% in men.
The total contribution of nontraditional risk factors was likely an underestimate because some such factors, including the autoimmune disorder antiphospholipid syndrome and patent foramen ovale, “lacked reliable administrative algorithms” and could not be assessed in this study, the researchers noted.
Further research on how nontraditional risk factors affect strokes could lead to better prevention.
“We need to better understand the underlying mechanisms of these nontraditional risk factors to develop targeted interventions,” Dr. Leppert said.
The study was funded by the National Institutes of Health/National Center for Advancing Translational Sciences Colorado Clinical and Translational Science Award. Dr. Leppert reports receiving an American Heart Association Career Development Grant. Other disclosures are included in the original article.
A version of this article appeared on Medscape.com.
, new research showed.
The findings may offer insight into the increased incidence of stroke in adults under age 45, which has more than doubled in the past 20 years in high-income countries, while incidence in those over 45 has decreased.
Investigators believe the findings are important because most conventional prevention efforts focus on traditional risk factors.
“The younger they are at the time of stroke, the more likely their stroke is due to a nontraditional risk factor,” lead author Michelle Leppert, MD, an assistant professor of neurology at the University of Colorado School of Medicine, Aurora, Colorado, said in a news release.
The findings were published online in Circulation: Cardiovascular Quality and Outcomes.
Traditional Versus Nontraditional
The researchers retrospectively analyzed 2618 stroke cases (52% female; 73% ischemic stroke) that resulted in an inpatient admission and 7827 controls, all aged 18-55 years. Data came from the Colorado All Payer Claims Database between January 2012 and April 2019. Controls were matched by age, sex, and insurance type.
Traditional risk factors were defined as being a well-established risk factor for stroke that is routinely noted during stroke prevention screenings in older adults, including hypertension, diabetes, hyperlipidemia, sleep apnea, cardiovascular disease, alcohol, substance use disorder, and obesity.
Nontraditional risk factors were defined as those that are rarely cited as a cause of stroke in older adults, including migraines, malignancy, HIV, hepatitis, thrombophilia, autoimmune disease, vasculitis, sickle cell disease, heart valve disease, renal failure, and hormonal risk factors in women, such as oral contraceptives, pregnancy, or puerperium.
Overall, traditional risk factors were more common in stroke cases, with nontraditional factors playing a smaller role. However, among adults aged 18-34 years, more strokes were associated with nontraditional than traditional risk factors in men (31% vs 25%, respectively) and in women (43% vs 33%, respectively).
Migraine, the most common nontraditional risk factor for stroke in this younger age group, was found in 20% of men (odds ratio [OR], 3.9) and 35% of women (OR, 3.3).
Other notable nontraditional risk factors included heart valve disease in both men and women (OR, 3.1 and OR, 4.2, respectively); renal failure in men (OR, 8.9); and autoimmune diseases in women (OR, 8.8).
An Underestimate?
The contribution of nontraditional risk factors declined with age. After the age of 44, they were no longer significant. Hypertension was the most important traditional risk factor and increased in contribution with age.
“There have been many studies demonstrating the association between migraines and strokes, but to our knowledge, this study may be the first to demonstrate just how much stroke risk may be attributable to migraines,” Dr. Leppert said.
Overall, women had significantly more risk factors for stroke than men. Among controls, 52% and 34% of women had at least one traditional and nontraditional risk factors, respectively, compared with 48% and 22% in men.
The total contribution of nontraditional risk factors was likely an underestimate because some such factors, including the autoimmune disorder antiphospholipid syndrome and patent foramen ovale, “lacked reliable administrative algorithms” and could not be assessed in this study, the researchers noted.
Further research on how nontraditional risk factors affect strokes could lead to better prevention.
“We need to better understand the underlying mechanisms of these nontraditional risk factors to develop targeted interventions,” Dr. Leppert said.
The study was funded by the National Institutes of Health/National Center for Advancing Translational Sciences Colorado Clinical and Translational Science Award. Dr. Leppert reports receiving an American Heart Association Career Development Grant. Other disclosures are included in the original article.
A version of this article appeared on Medscape.com.
FROM CIRCULATION: CARDIOVASCULAR QUALITY AND OUTCOMES