- Email: [email protected]
ATOMOXETINE FOR HOARDING DISORDER: A PRECLINICAL AND CLINICAL INVESTIGATION
612
PILOT STUDY EXAMINING THE POTENTIAL USE OF THE PSYCHOEDUCATION COMPONENT OF DANGER IDEATION REDUCTION THERAPY (DIRT) AS AN ADJUNCT TO TREATMENT FOR CONTAMINATION FEARS IN PATIENTS WITH PROFOUND REFRACTORY OBSESSIVE COMPULSIVE DISORDER
Anushka Dissanayake1, Lynne M Drummond1,2 National Obsessive Compulsive and Body Dysmorphic Disorder Service, SW London and St Georges Mental Health NHS Trust, London SW17 7DJ 2St George’s, University of London, London SW17 ORE
B. Dell'Osso et al. Summary: The feedback of the pilot study has showed that it was well received and appreciated. Sample size being small and data being qualitative nature has been the two main limitations. A further study of a larger sample with more structured monitoring of progress in profound refractory OCD will be worth exploring.
1
Declaration of interests We declare no competing interests.
Policy and Ethics Background: The psychoeducational approach of Danger Ideation Reduction Therapy (DIRT) was developed and researched in Australia. There have been limited trials in other countries. Indeed, there are extremely few publications highlighting the use of DIRT outside Australia (Govender, Drummond and Menzies, 2006, Drummond and Kolb,). Methods: All patients who had a contamination fears and who were inpatients at the time of the pilot study (5th May 2015 – 19th May 2015) were asked to attend a series of 3 Psychoeducational Groups. The groups were weekly and covered the following topics: • Combined session of Statistics on contamination and HIV/AIDS • Immune system • Faeces and Vomitus These groups were prepared and delivered by the Wardbased junior doctor with the assistance of medical students attached to the Ward. All patients continued to receive appropriate psychopharmacological treatment as well as treatment involving Graded Exposure and self-imposed Response Prevention alongside those groups. At the end of the pilot patients were asked for their feedback. The qualitative data obtained from the patients were analyzed. Results: Feedback from the participating patients revealed the following qualitative data: Provision of relevant, practical information on various health issues, relevant to people having OCD fears regarding possibility of catching various infection Provision of factual information was useful. It was an eye opener to know about the statistics and to realise how slim the chances of contamination are. Facts were provided in relation to the actual risks of acquiring various diseases rather than the risk/ fears in this regard or perceived by various OCD sufferers Understood about the digestive system, how it works, what faeces is made of (mainly water) Learnt that getting HIV off people is very rare. Acquired a good understanding about the natural defence mechanisms of the body. Discussion: The study is small and is a pilot study. However it demonstrates that the Psychoeducational component of DIRT delivered in group format to a group of profound refractory OCD patients is generally well received and appreciated. Full studies need to continue to examine the efficacy of this approach.
Due to the nature of the study ethical clearance was not required.
References [1] Boschen,M.J., Drummond,L.M. , Pillay,A. And Morton, K. (2010) Predicting Outcome of Treatment for Severe, Treatment Resistant OCD in Inpatient and Community Settings. Journal of Behaviour Therapy and Experimental Psychiatry , 41, 90-95 [2] Drummond,L.M., Boschen,M.J., Cullimore,J,KhanHameed,A,White,S. And Ion,R. (2012) Physical complications of severe, chronic obsessive-compulsive disorder:a comparison with general psychiatric inpatients General Hospital Psychiatry, 34(6):618-25 [3] Drummond,L.M. and Kolb,Pj (2008)Obsessive Compulsive Contamination Fears and Anorexia Nervosa; the Application of the New Psychoeducational Treatment of Danger Ideation Reduction Therapy (D.I.R.T.)., Behaviour Change , 25:1,44-49 http://dx.doi.org/10.1016/j.euroneuro.2016.07.015
ATOMOXETINE FOR HOARDING DISORDER: A PRECLINICAL AND CLINICAL INVESTIGATION
Giacomo Grassi, M.D., Laura Micheli, Ph.D., Lorenzo Di Cesare Mannelli, Ph.D., Elisa Compagno, M.D., Carla Ghelardini, Ph.D., Stefano Pallanti, M.D., Ph.D. Department of Neuroscience, Psychology, Drug Research and Child Health – Neurofarba – Pharmacology and Toxicology Section, University of Florence, Florence, Italy
Purpose of the study: Hoarding disorder is a mental disorder that has been newly included in the DSM-5 into the obsessive-compulsive and related disorders chapter. To date only two open studies investigated the pharmacological management of hoarding disorder and its management remains controversial. Despite some studies suggested that childhood attention-deficit hyperactivity disorder (ADHD) and inattention symptoms may be related to hoarding [1],
Abstracts of the ICOCS 11th Scientific Meeting only a small case series study investigated the effectiveness of ADHD medications (metilphenidate) in hoarding disorder [2]. The aim of the present study was to evaluate the preclinical and clinical effectiveness of atomoxetine, a noradrenaline reuptake inhibitor approved for childhood and adulthood ADHD, in an animal model of compulsivelike behaviors (marble burying test) and in two patients with a primary diagnosis of hoarding disorder. Methods: We performed a preclinical investigation assessing the effects of atomoxetine on the marble burying behavior test in mice. During the test, mice were placed individually in a clear plastic box containing 24 black marbles (1 cm diameter), evenly spaced on 5 cm sawdust. The number of marbles buried (to at least 60% of the depth of the sawdust) within 30 min in vehicle and atomoxetine treated groups was measured. Atomoxetine (10, 30 and 60 mg kg-1) was administered per os 30 min before the test. Subsequently, we conducted a clinical investigation on two patients fulfilling the DSM-5 criteria for hoarding disorder. These patients were treated with atomoxetine 40-100 mg for 12 weeks. A history of adult or childhood ADHD was excluded through the diagnostic interview DIVA 2.0. No changes of the ongoing medications or psychotherapy were allowed during the treatment period. To measure the severity of hoarding, the Saving Inventory-Revised (SI-R) and the UCLA Hoarding Severity Scale (UHSS) were administered before and after the treatment. Response was defined as a more of 30% decrease in UHSS and SI-R scores and at least “much improved” on the Clinical Global Impression/ Improvement (CGI-I) scale. Results: Atomoxetine significantly reduced the number of buried marbles in a dose dependent manner in comparison to control mice, without affecting the locomotor activity. Atomoxetine (30 and 60 mg kg-1) significantly reduced the number of buried marbles in a dose dependent manner (12.3 7 1.0 and 10.0 7 1.8, respectively) in comparison to control mice (19.3 7 1.0), without affecting the locomotor activity. Atomoxetine 10 mg kg-1 was not effective (21.3 7 0.9). Atomoxetine-treated patients were both classified as treatment responders after 12 weeks of treatment. Atomoxetine was well tolerated during all the treatment period. Furthermore, both patients as were still classified responders at the 6 months follow-up visits. Conclusions: These preclinical and clinical data suggest that atomoxetine may be considered as a potentially effective compound for hoarding disorder. Therefore, atomoxetine should be considered for future controlled trials in hoarding disorder.
[1] Fullana, M.A., Vilagut, G., Mataix-Cols, D., Adroher, N.D., Bruffaerts, R., Bunting, B., de Almeida, J.M., Florescu, S., de Girolamo, G., de Graaf, R., Haro, J.M., Kovess, V., Alonso, J., 2013. Is ADHD in childhood associated with lifetime hoarding symptoms? An epidemiological study. Depress Anxiety 30(8),741-8. [2] Rodriguez, C.I., Bender, J. Jr., Morrison, S., Mehendru, R., Tolin, D., Simpson, H.B., 2013. Does extended release methylphenidate help adults with hoarding disorder?: a case series. J Clin Psychopharmacol 33(3), 444-7. Psychiatry Res. 2014 Mar 30;215(3):659-67. http:dx.doi. org/10.1016/j.psychres.2013.12.026. Epub 2013 Dec 21.
613 The profile of executive function in OCD hoarders and hoarding disorder. Morein-Zamir S1, Papmeyer M2, Pertusa A3, Chamberlain SR4, Fineberg NA5, Sahakian BJ4, Mataix-Cols D6, Robbins TW2. http://dx.doi.org/10.1016/j.euroneuro.2016.07.016
TOLERATING UNCERTAINTY IN OCD, DO PATIENTS REQUIRE MORE INFORMATION TO MAKE DECISIONS?
Sharon Morein-Zamir1,2,3, Sonia Shahper4, Julia Gasull Camos2,3, Alice Deruix2,3, Yulia Worbe2, Naomi A. Fineberg4,5, Trevor W. Robbins2,3 1Department of Psychology, Anglia Ruskin University, Cambridge, CB1 1PT, UK 2Behavioural and Clinical Neuroscience Institute, University of Cambridge, Cambridge, CB2 3EB, UK 3Department of Psychology, University of Cambridge, Cambridge, CB2 3EB, UK 4Postgraduate Medical School, University of Hertfordshire, College Lane, Hatfield, UK 5Highly Specialized Obsessive Compulsive and Related Disorders Service, Hertfordshire Partnership University NHS Foundation Trust, Rosanne House, Parkway , Welwyn Garden City, Hertfordshire, AL8 6HG, UK
Patients with OCD often report difficulties in decision making, however, formalized tests do not show consistent evidence of such abnormalities. One aspect of decision making that could lead to everyday impairments is unusually high levels of intolerance of uncertainty, whereby individuals perceive and respond abnormally in uncertain situations. High intolerance of uncertainty, believed to characterize several anxiety disorders as well as OCD, may be linked to indecisiveness or increased deliberation, as individuals strive to increase the level of evidence accumulated before making a decision. In the Beads Task, participants judge from which of two jars containing different mixtures of coloured beads, beads are repeatedly being selected. Preliminary evidence has suggested that compared with control participants OCD patients tend to request a greater number of beads before arriving at a decision, supporting the hypothesis above. We examined performance in the beads task together with self-reported intolerance of uncertainty levels and OC symptoms in a sample of 50 OCD patients and 47 age and gender matched healthy volunteers and in a separate sample of 66 healthy volunteers. Patients with OCD did not differ from control volunteers in the number of beads requested prior to making a decision. Similarly, healthy volunteers characterized by high versus low OC symptoms or intolerance of uncertainty did not differ in this regard. Additional measures, looking at degree of certainty (confidence) showed preliminary group differences between patients and controls. However, close inspection of performance indicated some participants did not comply with task instructions, likely due to difficulties in comprehension. On exclusion of these participants, group differences were no longer apparent. At the same time, groups differed markedly on self-reported
PILOT STUDY EXAMINING THE POTENTIAL USE OF THE PSYCHOEDUCATION COMPONENT OF DANGER IDEATION REDUCTION THERAPY (DIRT) AS AN ADJUNCT TO TREATMENT FOR CONTAMINATION FEARS IN PATIENTS WITH PROFOUND REFRACTORY OBSESSIVE COMPULSIVE DISORDER
Anushka Dissanayake1, Lynne M Drummond1,2 National Obsessive Compulsive and Body Dysmorphic Disorder Service, SW London and St Georges Mental Health NHS Trust, London SW17 7DJ 2St George’s, University of London, London SW17 ORE
B. Dell'Osso et al. Summary: The feedback of the pilot study has showed that it was well received and appreciated. Sample size being small and data being qualitative nature has been the two main limitations. A further study of a larger sample with more structured monitoring of progress in profound refractory OCD will be worth exploring.
1
Declaration of interests We declare no competing interests.
Policy and Ethics Background: The psychoeducational approach of Danger Ideation Reduction Therapy (DIRT) was developed and researched in Australia. There have been limited trials in other countries. Indeed, there are extremely few publications highlighting the use of DIRT outside Australia (Govender, Drummond and Menzies, 2006, Drummond and Kolb,). Methods: All patients who had a contamination fears and who were inpatients at the time of the pilot study (5th May 2015 – 19th May 2015) were asked to attend a series of 3 Psychoeducational Groups. The groups were weekly and covered the following topics: • Combined session of Statistics on contamination and HIV/AIDS • Immune system • Faeces and Vomitus These groups were prepared and delivered by the Wardbased junior doctor with the assistance of medical students attached to the Ward. All patients continued to receive appropriate psychopharmacological treatment as well as treatment involving Graded Exposure and self-imposed Response Prevention alongside those groups. At the end of the pilot patients were asked for their feedback. The qualitative data obtained from the patients were analyzed. Results: Feedback from the participating patients revealed the following qualitative data: Provision of relevant, practical information on various health issues, relevant to people having OCD fears regarding possibility of catching various infection Provision of factual information was useful. It was an eye opener to know about the statistics and to realise how slim the chances of contamination are. Facts were provided in relation to the actual risks of acquiring various diseases rather than the risk/ fears in this regard or perceived by various OCD sufferers Understood about the digestive system, how it works, what faeces is made of (mainly water) Learnt that getting HIV off people is very rare. Acquired a good understanding about the natural defence mechanisms of the body. Discussion: The study is small and is a pilot study. However it demonstrates that the Psychoeducational component of DIRT delivered in group format to a group of profound refractory OCD patients is generally well received and appreciated. Full studies need to continue to examine the efficacy of this approach.
Due to the nature of the study ethical clearance was not required.
References [1] Boschen,M.J., Drummond,L.M. , Pillay,A. And Morton, K. (2010) Predicting Outcome of Treatment for Severe, Treatment Resistant OCD in Inpatient and Community Settings. Journal of Behaviour Therapy and Experimental Psychiatry , 41, 90-95 [2] Drummond,L.M., Boschen,M.J., Cullimore,J,KhanHameed,A,White,S. And Ion,R. (2012) Physical complications of severe, chronic obsessive-compulsive disorder:a comparison with general psychiatric inpatients General Hospital Psychiatry, 34(6):618-25 [3] Drummond,L.M. and Kolb,Pj (2008)Obsessive Compulsive Contamination Fears and Anorexia Nervosa; the Application of the New Psychoeducational Treatment of Danger Ideation Reduction Therapy (D.I.R.T.)., Behaviour Change , 25:1,44-49 http://dx.doi.org/10.1016/j.euroneuro.2016.07.015
ATOMOXETINE FOR HOARDING DISORDER: A PRECLINICAL AND CLINICAL INVESTIGATION
Giacomo Grassi, M.D., Laura Micheli, Ph.D., Lorenzo Di Cesare Mannelli, Ph.D., Elisa Compagno, M.D., Carla Ghelardini, Ph.D., Stefano Pallanti, M.D., Ph.D. Department of Neuroscience, Psychology, Drug Research and Child Health – Neurofarba – Pharmacology and Toxicology Section, University of Florence, Florence, Italy
Purpose of the study: Hoarding disorder is a mental disorder that has been newly included in the DSM-5 into the obsessive-compulsive and related disorders chapter. To date only two open studies investigated the pharmacological management of hoarding disorder and its management remains controversial. Despite some studies suggested that childhood attention-deficit hyperactivity disorder (ADHD) and inattention symptoms may be related to hoarding [1],
Abstracts of the ICOCS 11th Scientific Meeting only a small case series study investigated the effectiveness of ADHD medications (metilphenidate) in hoarding disorder [2]. The aim of the present study was to evaluate the preclinical and clinical effectiveness of atomoxetine, a noradrenaline reuptake inhibitor approved for childhood and adulthood ADHD, in an animal model of compulsivelike behaviors (marble burying test) and in two patients with a primary diagnosis of hoarding disorder. Methods: We performed a preclinical investigation assessing the effects of atomoxetine on the marble burying behavior test in mice. During the test, mice were placed individually in a clear plastic box containing 24 black marbles (1 cm diameter), evenly spaced on 5 cm sawdust. The number of marbles buried (to at least 60% of the depth of the sawdust) within 30 min in vehicle and atomoxetine treated groups was measured. Atomoxetine (10, 30 and 60 mg kg-1) was administered per os 30 min before the test. Subsequently, we conducted a clinical investigation on two patients fulfilling the DSM-5 criteria for hoarding disorder. These patients were treated with atomoxetine 40-100 mg for 12 weeks. A history of adult or childhood ADHD was excluded through the diagnostic interview DIVA 2.0. No changes of the ongoing medications or psychotherapy were allowed during the treatment period. To measure the severity of hoarding, the Saving Inventory-Revised (SI-R) and the UCLA Hoarding Severity Scale (UHSS) were administered before and after the treatment. Response was defined as a more of 30% decrease in UHSS and SI-R scores and at least “much improved” on the Clinical Global Impression/ Improvement (CGI-I) scale. Results: Atomoxetine significantly reduced the number of buried marbles in a dose dependent manner in comparison to control mice, without affecting the locomotor activity. Atomoxetine (30 and 60 mg kg-1) significantly reduced the number of buried marbles in a dose dependent manner (12.3 7 1.0 and 10.0 7 1.8, respectively) in comparison to control mice (19.3 7 1.0), without affecting the locomotor activity. Atomoxetine 10 mg kg-1 was not effective (21.3 7 0.9). Atomoxetine-treated patients were both classified as treatment responders after 12 weeks of treatment. Atomoxetine was well tolerated during all the treatment period. Furthermore, both patients as were still classified responders at the 6 months follow-up visits. Conclusions: These preclinical and clinical data suggest that atomoxetine may be considered as a potentially effective compound for hoarding disorder. Therefore, atomoxetine should be considered for future controlled trials in hoarding disorder.
[1] Fullana, M.A., Vilagut, G., Mataix-Cols, D., Adroher, N.D., Bruffaerts, R., Bunting, B., de Almeida, J.M., Florescu, S., de Girolamo, G., de Graaf, R., Haro, J.M., Kovess, V., Alonso, J., 2013. Is ADHD in childhood associated with lifetime hoarding symptoms? An epidemiological study. Depress Anxiety 30(8),741-8. [2] Rodriguez, C.I., Bender, J. Jr., Morrison, S., Mehendru, R., Tolin, D., Simpson, H.B., 2013. Does extended release methylphenidate help adults with hoarding disorder?: a case series. J Clin Psychopharmacol 33(3), 444-7. Psychiatry Res. 2014 Mar 30;215(3):659-67. http:dx.doi. org/10.1016/j.psychres.2013.12.026. Epub 2013 Dec 21.
613 The profile of executive function in OCD hoarders and hoarding disorder. Morein-Zamir S1, Papmeyer M2, Pertusa A3, Chamberlain SR4, Fineberg NA5, Sahakian BJ4, Mataix-Cols D6, Robbins TW2. http://dx.doi.org/10.1016/j.euroneuro.2016.07.016
TOLERATING UNCERTAINTY IN OCD, DO PATIENTS REQUIRE MORE INFORMATION TO MAKE DECISIONS?
Sharon Morein-Zamir1,2,3, Sonia Shahper4, Julia Gasull Camos2,3, Alice Deruix2,3, Yulia Worbe2, Naomi A. Fineberg4,5, Trevor W. Robbins2,3 1Department of Psychology, Anglia Ruskin University, Cambridge, CB1 1PT, UK 2Behavioural and Clinical Neuroscience Institute, University of Cambridge, Cambridge, CB2 3EB, UK 3Department of Psychology, University of Cambridge, Cambridge, CB2 3EB, UK 4Postgraduate Medical School, University of Hertfordshire, College Lane, Hatfield, UK 5Highly Specialized Obsessive Compulsive and Related Disorders Service, Hertfordshire Partnership University NHS Foundation Trust, Rosanne House, Parkway , Welwyn Garden City, Hertfordshire, AL8 6HG, UK
Patients with OCD often report difficulties in decision making, however, formalized tests do not show consistent evidence of such abnormalities. One aspect of decision making that could lead to everyday impairments is unusually high levels of intolerance of uncertainty, whereby individuals perceive and respond abnormally in uncertain situations. High intolerance of uncertainty, believed to characterize several anxiety disorders as well as OCD, may be linked to indecisiveness or increased deliberation, as individuals strive to increase the level of evidence accumulated before making a decision. In the Beads Task, participants judge from which of two jars containing different mixtures of coloured beads, beads are repeatedly being selected. Preliminary evidence has suggested that compared with control participants OCD patients tend to request a greater number of beads before arriving at a decision, supporting the hypothesis above. We examined performance in the beads task together with self-reported intolerance of uncertainty levels and OC symptoms in a sample of 50 OCD patients and 47 age and gender matched healthy volunteers and in a separate sample of 66 healthy volunteers. Patients with OCD did not differ from control volunteers in the number of beads requested prior to making a decision. Similarly, healthy volunteers characterized by high versus low OC symptoms or intolerance of uncertainty did not differ in this regard. Additional measures, looking at degree of certainty (confidence) showed preliminary group differences between patients and controls. However, close inspection of performance indicated some participants did not comply with task instructions, likely due to difficulties in comprehension. On exclusion of these participants, group differences were no longer apparent. At the same time, groups differed markedly on self-reported