H. Blair Simpson, MD, PhD

[[{"type":"media","view_mode":"media_crop","fid":"23790","attributes":{"alt":"OCD","class":"media-image media-image-right","id":"media_crop_3468746537599","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4150","media_crop_rotate":"0","media_crop_scale_h":"116","media_crop_scale_w":"125","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image"}}]]In recent years, the increasing number of computer and Internet users has greatly expanded the potential to access evidence-based care for the treatment of psychiatric disorders. Computer-assisted and Internet-based treatments expand accessibility of treatment for individuals who may have economic, transportation, or other restrictions that limit access to face-to-face services. Furthermore, these programs have the advantages of increasing cost-effectiveness of evidence-based treatments by reducing contact time with a therapist, broadening client participation in therapy-based activities in real-world settings, and monitoring quality of care and client progress.

Researchers have developed programs that range from self-directed therapy based on “self-help” models to therapist-supported interactive treatments with or without video conferencing. Much of the research on computer or Internet-based programs has been focused on anxiety disorders.

 Given the severe and disabling nature of obsessive-compulsive disorder (OCD), numerous efforts have been made to improve access to evidence-based treatment for those facing barriers to care.

OCD is associated with a profoundly diminished quality of life, social isolation, and a substantial economic burden on society; the lifetime prevalence of OCD is 2%.

 It is characterized by the presence of persistent and distressing thoughts and worries-obsessions-and repetitive or ritualized behaviors-compulsions. Most often the compulsions are carried out in direct response to the obsessions and serve to reduce anxiety and distress.

Evidence-based guidelines identify 2 types of effective treatments of OCD: medications, including SNRIs (eg, clomipramine) and SSRIs, and cognitive-behavioral therapy (CBT) consisting of exposure and response prevention (ERP). With ERP, patients gradually expose themselves to their fears or obsessions while refraining from engaging in rituals or compulsions. Exposures are conducted in a systematic fashion starting with situations that are least feared and gradually working toward situations that are most feared. Despite the documented efficacy of ERP, few patients receive this treatment in clinical practice, although many patients prefer CBT to medication alone and CBT is superior to antipsychotic medications as an augmentation strategy for those experiencing residual symptoms.

 Barriers to care include uncertainty about where to seek treatment, lack of trained therapists, shame and stigma associated with mental health problems, time limitations, competing demands, and costs associated with seeking psychological care.

Multiple efforts have been made to improve access to CBT for patients with OCD; among these, an Internet-based CBT (I-CBT) for OCD, developed at the Karolinska Institutet in Sweden, is the most promising program developed to date.

 In I-CBT, individuals use an Internet-based treatment platform to learn about their illness and to engage in ERP under the confidential guidance of an expert therapist. I-CBT overcomes many barriers to care and allows individuals to receive evidence-based ERP treatment under the guidance of trained therapists without the traditional restrictions and requirements of face-to-face meetings.

In one trial, I-CBT was found to be far superior to a control treatment (response to treatment: 60% for I-CBT vs 6% for control); I-CBT also had low dropout rates (12%), comparable to rates seen in face-to-face treatment.

 Moreover, decreases in OCD severity with I-CBT are comparable to those with face-to-face ERP. I-CBT is a clear advance over other self-help programs because it is a single, integrated system of treatment supported by a therapist accessible anywhere via the Internet. This program has the potential to substantially affect public health and enable underserved OCD patients to access evidence-based care. However, I-CBT has never been tested outside of Sweden in diverse OCD patient populations and settings. It is exciting to see effects of I-CBT in Sweden, and we look forward to seeing how such a program might fare in the US. This type of innovation could change how we treat anxiety disorders, including OCD.

Dr Patel is Research Scientist at the New York State Psychiatric Institute and Assistant Professor of Clinical Psychology in the department of psychiatry of Columbia University, College of Physicians and Surgeons, New York (for information about a pilot research study on I-CBT, you can contact Dr Patel at Sapatel@nyspi.columbia.edu). Dr Schmidt is Clinical Researcher at the New York State Psychiatric Institute. Dr Simpson is Director of the Anxiety Disorders Clinic and Center for OCD and Related Disorders at the New York State Psychiatric Institute and Professor of Psychiatry at Columbia University, College of Physicians and Surgeons. The authors report no conflicts of interest concerning the subject matter of this article.

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 Andersson E, Enander J, AndrÃ©n P, et al. Internet-based cognitive behaviour therapy for obsessive-compulsive disorder: a randomized controlled trial. 

Articles

Internet-based CBT has shown promise to improve access to therapy for patients with OCD, which is associated with a profoundly diminished quality of life and social isolation.

Using the Internet to Increase Access to Evidence-Based Treatment for Obsessive-Compulsive Disorder

 discuss current clinical research and the future of treatment options for obsessive-compulsive disorder (OCD). They address the biology and the brain mechanisms related to OCD symptoms, as well as new research initiatives. Also discussed are elements of the 

NIMH Research Domain Criteria (RDoC) project

, as well as a look at clinical trials currently underway.

Dr Simpson is Director of the Anxiety Disorders Clinic and the Center for OCD and Related Disorders at the New York State Psychiatric Institute/Columbia University Medical Center. Dr Rynn is Director of the Division of Child and Adolescent Psychiatry and Pediatric Anxiety and Mood Research Clinic at the New York State Psychiatric Institute/Columbia University Medical Center in New York.

For more information on treatment of OCD and research opportunities at Columbia, 

. This podcast was moderated by Marcia Kimeldorf, PhD, and edited by 

 with permission from Columbia University Department of Psychiatry. The full discussion can be heard at BlogTalkRadio 

Using Technology to Disseminate CBT for OCD

Podcasts

In this podcast, two psychiatrists discuss current clinical research and the future of treatment options for obsessive-compulsive disorder. 

OCD: Current Research and Future Directions

What do we know about the relative efficacy of current medication and [cognitive-behavioral] therapy (CBT) for OCD? Dr H. Blair Simpson answers that question and discusses future directions and causes in the study of OCD.

Dr Simpson is funded by the National Institute of Mental Health (NIMH).

Her team is recruiting adults for an OCD treatment study. Information can be found at:


In collaboration with Dr Edna Foa at the University of Pennsylvania, our clinic did a study to exactly answer the question. The data from that study showed very clearly that the therapy-when delivered by highly trained therapists and well supervised with patients who adhere to the treatment-is at least as good if not better than the medication. So that is surprising for psychiatrists to know. That's why either the medication or the therapy are first-line treatments for OCD.

Many people make the assumption [and ask] what happens when you put [medication and therapy] together [and wonder if] that [would be] better still. The interesting thing about that first study is that's not what we found. We found that the medication and the therapy together were no better than the therapy alone. There are a couple of important caveats. In that study, the medication and the therapy were started at the same time [and medication can take up to 6 weeks to work]. The therapy in that study was delivered not twice weekly, but 5 days a week for 3 weeks within a week of home visits so the therapy [was intensive over a month's duration]. So that combination cell in essence was like a month of intensive therapy and the ["rocket booster" at the end] was medication. So what I would say is that no, you do not need to start people . . . all people do not need to start on combination. They can start with medication, or start with the therapy.

If people get a partial response to medication, we have now done 2 studies, again in collaboration with Dr Edna Foa at the University of Pennsylvania that show definitively that adding CBT on top of people who have gotten the most that they are going to get out of their medication will help more people get well. In those subsequent studies, everyone came in on a stable dose of their serotonin reuptake inhibitor (SRI) medication. They had been on it for at least 12 weeks on the maximum dose. They weren't going to get anything more from their medication.

One study randomized them to exposure and ritual prevention (ERP) treatment versus a control therapy where we were able to control for attention and support and coming to our clinic with a research staff. We could show clearly that the control therapy didn't do much. By adding ERP treatment on top of the medication, many people (70%) responded and a third got well. That study was comparing adding exposure therapy versus adding antipsychotic medication, which is right now the only other treatment we have for people who have a partial response to SRI medication. Again, people came in on their SRI medication; all of them had been in on their highest dose for at least 12 weeks and they weren't going to get anything more from their SRI. This is the situation that psychiatrists are going to [encounter].

The question becomes what do you do? This was a study where we compared adding ERP treatment versus adding antipsychotic medication-in the study we used risperidone because the evidence was best for risperidone in OCD-versus a placebo. What we found in that study is that once again with ERP treatment 80% of people responded and 43% were well after 17 sessions. Moreover, we have also shown that if you get well, you are very likely to maintain your response out to 6 months if you have gotten well from ERP.

The big picture is there are SRI medications as a first-line treatment. There is this very particular type of CBT as a first-line treatment. When you get a partial response to SRI medication, the first thing you should be thinking about is adding the CBT on top. With all the caveats I've given you, that if you have a patient who cannot adhere to the treatment, then you're not going to get the good results that we can get in our studies. If the therapist isn't giving the right treatment, you're not going to get the good results that you get in our studies. That's where as a psychiatrist, once you've tried those options, you [use treatments] that are less evidence-based to try to help your patients.


We [are] interested in who the people are who get well once they have been given an SRI medication and then CBT/ERP added on top? As I said, about 70% to 80% of people will respond to that combination and about 35% to 40% of people will get well at the end of that added-on 17 sessions. And if you give some people a little bit more, maybe as high as 60% will get well.

So now [a patent is] well. They have been on the medication for a long time, they received the CBT added on top . . . the first thing those patients ask us is, "Do I still need my medication?" That is an important clinical question and we're really thrilled. Edna Foa and I are funded by the National Institute of Mental Health to answer that exact question. We're currently both at our site and at the University of Pennsylvania doing a study where people on SRIs who are at their maximum dose and have been there for 12 weeks (they're not going to get more from their medication) come to us. They get this very specific therapy added on top first and with the people are well, we then are going to randomize to half of them (not known to them and not known to us) will stay on their medication for the next 6 months and half of them will be tapered to a pill placebo . . . our sense of it is that some people may actually be able to come off their medication but at this moment we don't know who can do that. Hopefully another study to really look at . . . who gets well with this combination of treatment and who doesn't, who gets well enough that actually it's safe and good for them to slowly taper off their SRI, and who should not come off their SRI medication-that's the point of the study.

If there are people who are watching this video or you have patients who think might be appropriate for the study, please go to our study website. Again, the study is being run in both Philadelphia and New York. We think it's a great study and frankly for patients who haven't had this combination, here is how you can get treatment you should be getting at no cost to you as well as you can help us advance the field and [potentially] help a much broader population of patients.


There are 2 ways to think about this. Any behavior I have is because my brain is causing that behavior. I'm talking to you now because I have circuits in my brain that allow me to speak, that move my tongue. In that sense, if I have obsessions and compulsions, my brain is causing me to have obsessions and compulsions.

We can study that by doing brain imaging studies of people who have OCD and people who don't and look for what is different about how their brain is functioning. What we know from human imaging studies is that there is a hyperactive brain circuit in people with OCD that is not present in people without OCD and it includes brain regions called the orbital frontal cortex, the striatum, and the thalamus. These brain areas are connected to each other in a loop. The working model of OCD is that there is a hyperactive brain circuit and that is what is contributing to the symptoms of obsessions and compulsions.

That's what I would call pathophysiology: how does the brain produce a behavior. But it's a completely different question to ask, "How did my brain get like that in the first place?" That's a different way to look at cause. That's what I call etiology, which we know much less about.

The current thinking and there's some data to suggest some people have certain genes that may make people vulnerable. There are certain problems that may happen as your brain is getting set up during development. There are certain infections and post-infection syndromes that may lead in some people to OCD symptoms. There are case examples of people who had a neurological stroke or have a brain tumor in that brain circuit that can lead to OCD. So that's an area that's harder to study and that we know less about, but if you take what causes obsessions and compulsions is that abnormal circuit, then anything that can disrupt the normal circuit potentially could lead to OCD symptoms. That's a way to think about pathophysiology and etiology of what causes OCD.


Foa EB, Liebowitz MR, Kozak MJ, et al. Randomized, placebo-controlled trial of exposure and ritual prevention, clomipramine, and their combination in the treatment of obsessive-compulsive disorder. 

Simpson HB, Foa EB, Liebowitz MR, et al. A randomized, controlled trial of cognitive-behavioral therapy for augmenting pharmacotherapy in obsessive-compulsive disorder.  

Simpson HB, Foa EB, Liebowitz MR, et al. Cognitive-behavioral therapy vs risperidone for augmenting serotonin reuptake inhibitors in obsessive-compulsive disorder a randomized clinical trial serotonin reuptake inhibitor augmentation serotonin reuptake inhibitor augmentation. 

Dr Simpson is Professor of Clinical Psychiatry, Columbia University, and Director of the Anxiety Disorders Clinic and the Center for OCD and Related Disorders at New York State Psychiatric Institute in New York City,

What do we know about the relative efficacy of current medication and therapy for OCD? This question answered and highlights of recent studies, future directions, and causes are summarized in this video.

The Relative Efficacy of Current Medication and Therapy for OCD

In this video, Dr H. Blair Simpson gives a brief overview of the some of the treatments for obsessive-compulsive disorder (OCD).

Dr Simpson is Professor of Clinical Psychiatry, Columbia University, and Director of the Anxiety Disorders Clinic and the Center for OCD and Related Disorders at New York State Psychiatric Institute in New York City. Dr Simpson is funded by the National Institute of Mental Health (NIMH).

One pharmacological treatment is a class of medications called serotonin reuptake inhibitors and that class of medications includes medications like the selective serotonin reuptake inhibitors (SSRIs). These are medications [like fluoxetine (Prozac) or sertraline (Zoloft). One more, clomipramine (Anafranil), is an old-fashioned tricyclic antidepressant, but its primary action also works on the serotonin reuptake inhibitor in the brain.

Clomipramine plus the SSRIs (all serotonin reuptake inhibitors=SRIs) have been shown to be effective for OCD and all of them, with the exception of escitalopram (Lexapro) and citalopram (Celexa) have been approved by the Food and Drug Admistration (FDA) for the treatment of OCD. It is not that the other ones don't work . . . but they have not gone through FDA approval.

Big picture: Serotonin reuptake inhibitors, which include SSRIs, like fluoxetine, as well as clomipramine, all work in the treatment of OCD. There have been large multiple randomized controlled trials multisite.

The other first-line treatment we have for OCD is a type of psychotherapy, cognitive-behavioral therapy (CBT) of a very particular type. CBT is sort of a big umbrella term right now in the literature, and it can mean lots of different things . . . Specifically, we know what works for OCD is a type of CBT called exposure and response prevention, or sometimes also called exposure and ritual prevention. It has all sorts of acronyms in the literature-behavioral therapy, ExRP, ERP-but it is all the same thing. It is exposure and response and ritual prevention.

It is important for psychiatrists to know about medications as well as psychotherapeutic treatments and how to use them together. They also need to be able to evaluate when a patient says they have had therapy but it "didn't work." It is important to follow up and ask them what treatments they have had, because many people have not received treatment that is evidence-based.

An expert summarizes the effectiveness of the treatments for obsessive-compulsive disorder, including pharmacotherapy and a very specific type of cognitive behavioral therapy.

OCD: An Overview of Effective Treatments

In this video, Dr H. Blair Simpson gives a brief overview of the hallmarks, themes, and common comorbidities found in obsessive-compulsive disorder (OCD) and explains what to look for when treating OCD in connection with other psychiatric illnesses. Dr Simpson is Professor of Clinical Psychiatry, Columbia University, and Director of the Anxiety Disorders Clinic and the Center for OCD and Related Disorders at New York State Psychiatric Institute in New York City.

Dr Simpson is funded by the National Institute of Mental Health (NIMH). Her team is recruiting adults for an OCD treatment study. Information can be found at:



OCD is one of our most important psychiatric illnesses. People think about a lot of other disorders-schizophrenia, bipolar disorder, depression-but sometimes OCD doesn’t get as much recognition or enough awareness as it should. First, [OCD] is a very disabling illness. Many of the people who have it can be [very] impaired by it, and yet it is often hidden in the sense that it isn’t as dramatic or obvious so people often suffer in privacy.

[OCD] is relatively much more common than people thought; it is about 2% lifetime prevalence and in comparison, schizophrenia is 1%. It is more common than schizophrenia. Its onset is in adolescence or young adulthood, with about a quarter of cases starting in childhood. So again, putting it in perspective, about half of the cases of OCD will start by age 19 and in comparison, about half of the cases of depression start at age 32. So it has a much earlier age of onset. Typically, the course of it once you get it is typically chronic, waxing and waning symptoms.

Finally, the severity of it is much more than . . . other anxiety disorders. If you have the disorder, the vast majority will have moderate or severe symptoms.

If you add that all up-early onset, how common it is, chronic course, and severe symptoms-you can see that it can be very disabling. What happens is that people get the disorder relatively early in life and it can get them off track.


It’s in the name-obsessions and compulsions. So what are obsessions? Intrusive thoughts, images, or impulses that someone has that they don’t want and that they find very distressing. And what are compulsions? They are behaviors or mental acts that someone does over and over again to try to reduce the stress typically that the obsession has caused.

It is very important to realize that obsessions are not just thoughts. They can be images or impulses. For example, I worked with someone who had intrusive thoughts of coffins popping into his head all day long and it generated incredible distress . . . The other part of it is that compulsions are not just behaviors. They can be something that someone does over and over again in their head all day long. For example, the person who had those intrusive images of coffins . . . the compulsion was to then call up a positive image to try to neutralize the obsession.

[The vast majority of patients who seek clinical treatment have both obsessions and compulsions], and usually they’re related to each other. What I mean by that is there are certain themes that usually go together.


People will have intrusive thoughts about illness or about germs-and often the compulsion could be washing rituals. So the theme goes together.


That could be fear of harm befalling yourself or befalling someone you love. That can lead to a lot of checking behaviors or checking in your head that that harm didn’t actually occur.

Concerns about symmetry or things being “just right”


These are people who can actually either be spending hours arranging and ordering their home or office to make sure things are just aligned or it can be as they read or as they walk, making sure things are done in a certain number or a certain rhythm.


In general [hoarding] has been considered part of OCD, but the current thinking is that people who only hoard objects and have huge stashes of things and can’t get rid of things [are dealing with] a separate [issue]. But there is still a part of a hoarding behavior that can be part of OCD . . . someone who has a concern about harm (eg, don’t want to harm anyone), and they can’t let go of any of those newspapers that have medical information in them for fear that they might harm one of their extended family members or friends if they don’t send it to them. That would be an example of hoarding behavior but it is in the context of OCD.


These are sexual, religious, or aggressive thoughts. These are also very upsetting to people, such as doing things that are sacrilegious to your God, or awful sexual or aggressive images that the person doesn’t want.

Everybody with OCD has obsessions and compulsions; they need to be distressing, time consuming, and impairing. The actual content of the obsessions and compulsions can vary widely among patients, and one that most people know are the contamination and washing rituals, but this is only one of multiple themes that are common in OCD . . . there are many different contents and themes but they all have the same sort of organization of obsessions and compulsions.


People can not only have different themes and types of symptoms but they can also have different types of affects. What I mean by that is some people get very anxious when they get in front of one of their OCD triggers. They can have paralyzing anxiety, including panic attacks. It is not panic disorder; it’s OCD with panic attacks. Other people can have an intense sense of . . . not so much anxiety, but disgust. Another group can have a sense of increasing tension and a sense of things not being “just right.” So there is a range of affects that people can have with OCD; it’s not only anxiety.

There is also a range of insight . . . some OCD patients can say to you [what they’re feeling] doesn’t make any sense: “I know if I touch the subway pole on the New York City subway, I’m not going to get AIDS. That’s not how you get HIV.” Other people believe that if they touch that pole on the subway, they really might get ill and die. So that’s what I mean by a range of rationality about their OCD symptoms-some with good insight who can tell you these behaviors don’t make any sense but they can’t stop doing them; and a small minority actually have zero insight and . . . appear delusional. [However], that isn’t a psychotic disorder; it is absent insight in the context of OCD. So there is a range of insight . . . not just between individuals, but oftentimes over the trajectory of the illness. I often see adults, and the adults can say to me, “When I was 12 and I got that image, I . . . [believed] that my thoughts could kill my parents. I now realize that that was my OCD but back then, I really thought I could do it.” As people get educated about the illness, their insight improves because they realize their thoughts aren’t true, but at an earlier stage of the illness, they might not have been as sure.

The other thing is that sometimes people’s insight can change when you’re right in front of them. If I have someone in my office and we’re talking about their OCD, they can [say], “It doesn’t make any sense; I shouldn’t have to wash this much.” If I then go and do an exposure experiment with them in the New York City subway, right in front of me, they’ll lose their ability to know that this doesn’t make any sense, and they’ll be terrified.


So insight varies, different types of affects, and the themes of the OCD can vary . . . everyone has obsessions and compulsions or the vast majority-over 95% of people seeking treatment will have both, and they often have the relationship to each other-and that’s what you’re looking for diagnostically.

Sometimes people worry [that if they have an intrusive thought from time to time, they might have OCD]. It is important to distinguish OCD from normality. Everybody has intrusive thoughts-the funny image or thought pops in your head. Many people have what I would call habits. Most of us get anxious. If we’re flying to a distant city, we check more than once whether we have our airplane ticket before we go to the airport. Is that OCD? Absolutely not. Those are completely normal behaviors and it is how our brain works.

OCD is something very different, and if you actually see patients with OCD, it is not typically mild. It is usually moderate to severe, and these people spend [at least an hour a day-and many people spend 3, 5, 8 hours or all day-obsessing and compulsing] and their life is impaired. They often don’t socialize because of either the content of their obsessions and compulsions or because of the time it takes. They often are avoiding important things in their life to not trigger the OCD. You can see that it impacts [a person’s] work life, school life, and romantic relationships. So [OCD is] a very impairing illness.


The most common co-occurring psychiatric disorders that people with OCD have are other depressive disorders and other anxiety disorders, and those are the most frequent . . . So when you see someone with OCD, you should be doing a careful evaluation. Do they also have panic disorder? Do they also have social anxiety disorder? Do they have posttraumatic stress disorder? Making those distinctions is important in your treatment plan. Depression is often comorbid as well.

Other [comorbidities] that are lower on the list but often frequent: OCD often co-occurs with obsessive-compulsive personality disorder, which is a different thing than OCD. It isn’t mild OCD. Obsessive-compulsive personality disorder is a long-standing pattern of maladaptive perfection, rigidity, and emotional restraint. That combination and those types of personality traits coupled with OCD has been shown to . . . be a negative predictor for course in OCD, as well as in other disorders.

The other thing that can . . . occur in about a third of people is comorbid tic disorders. What I mean by that is chronic tic disorder as well as Tourette’s disorder.

Lower down on the list . . . for psychiatrists who see a lot of patients with schizophrenia, bipolar disorder, autism disorder, or eating disorders, the thing for you to know is that OCD is more common in those disorders than would be expected by its lifetime prevalence of 2%. For example, there are studies in patients with schizophrenia or schizoaffective disorder that maybe as many as 12% meet criteria for OCD as well, and there’s a higher rate of obsessive-compulsive symptoms in those psychotic disorders. My point here is OCD itself should be looked for at a 2% lifetime prevalence (more common than schizophrenia), but if you’re seeing a lot of patients with anxiety and depression, you should ask about OCD. If you’re seeing a lot of patients with eating disorders, autism, schizophrenia, tic disorders, or Tourette’s, you should definitely be asking for OCD. When you see OCD, you should definitely be [looking for] depression, anxiety, tic disorders, obsessive-compulsive personality disorder-because those will make a difference in your treatment plan.

 National Institute of Mental Health.
•Nauert R. 

Adding psychotherapy to medication treatment improves outcomes in pediatric OCD

. September 21, 2013. National Institute of Mental Health.