Effectiveness and outcome predictors of cognitive-behavioural therapy for obsessive-compulsive disorder co-occurring with psychosis

Efficacia e predittori di risposta alla terapia cognitiva nel disturbo ossessivo compulsivo in comorbidità con disturbi psicotici

A. Tundo, L. Salvati, L. Cieri, M. Daniele, D. Di Spigno, R. Necci, A. Parena

Istituto di Psicopatologia, Rome, Italy



The co-occurrence of obsessive-compulsive disorder (OCD) in patients with schizophrenia (SCH) or schizoaffective disorder (SA) is frequent (7.8%-25%) and is associated with a high risk of suicide, severe impairment of social behaviour, poor quality of life and poor prognosis. Data on the effectiveness of serotonin reuptake inhibitors in patients with SCH/SA OCD comorbidities are limited and controversial, and to date no study exploring the effectiveness of CBT for patients with this comorbid condition has been carried out. The aims of this investigation are to examine the effectiveness of CBT for OCD in patients with stabilized SCH/SA and to analyze the relationship of alcohol/ substance use disorder and temporal onset of OCD compared to that of SCH/SA and type of OCD (primary/secondary to second generation antipsychotics) with CBT outcomes in a naturalistic clinical setting.


Twenty-one consecutive patients with SCH/SA OCD comorbidity were enrolled. Inclusion criteria were: age 18-65 years; meeting DSM-IV criteria for OCD and either schizophrenia or schizoaffective disorder; OCD of at least moderate severity (Yale-Brown Obsessive Compulsive Scale [Y-BOCS] total score ? 16); 4) stabilized SCH or SA, even if symptoms were not entirely absent (Positive and Negative Symptoms Scale [PANSS] total score ? 75). Primary outcomes were: adherence rate, defined as the percentage of patients who did not drop out during the trial and the OCD remission rate, defined as a Y-BOCS total score < 16. Secondary outcomes were OCD response, defined as a ? 25% decrease in the total Y-BOCS score from baseline to 1 year, and a Clinical Global Impression-Improvement (CGI-I) score of ? 2 (“much” or “very much” improved). An intent-totreat analysis was performed.


One patient (4.7%) discontinued CBT after 1 session, and 4 patients (19%) dropped out of the study. The mean scores of YBOCS, CGI-S and Global Assessment of Functioning (GAF) scales showed statistically significant improvements at 6 months; from 6 to 12 months improvement continued, albeit at a slower rate. From baseline to 12 months, the mean total score reduction on the Y-BOCS was 8.5 points; on the Y-BOCS insight subscale it was 1 point, and on the CGI-S it was 1 point. General functioning also improved, as shown by a 6.7 point increase in GAF scores. At one year, 52% (11/21) of patients were rated as much/very much improved; 33% (7/21) were responders and 19% (4/21) were remitters. Compared with patients without alcohol/substance use, those with alcohol/substance use were significantly less likely to improve (68% vs. 0% p = 0.012). The percentage improved varied from 0% in patients in which the onset of OCD preceded that of SCH/SA to 50% in patients in which the OCD onset occurred after that of SCH/SA up to 83.3% in patients in which the onset of two disorders was simultaneous. No significant differences in outcome between patients with primary/secondary to second generation antipsychotics use OCD were found.


Our findings suggest that CBT is a helpful treatment for OCD in these difficult-to-treat patients, with a challenge posed by patients with lifetime alcohol/substance abuse disorder.

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