Cognitive-behavioral therapy for comorbid obsessive-compulsive disorder in patients with psychosis

Psychother Psychosom 2012;81:58–60 DOI: 10.1159/000329455

Cognitive-Behavioral Therapy for Obsessive- Compulsive Disorder as a Comorbidity with Schizophrenia or Schizoaffective Disorder

The co-occurrence of obsessive-compulsive disorder (OCD) in patients with schizophrenia (SCH) or schizoaffective disorder (SA) is quite common (7.8–25%) [1–6]. Obsessive-compulsive symptoms in patients with SCH are associated with severe psy- chosis, a high risk of suicide, severe impairment of social behavior and a poor prognosis [7–12]. Despite the high prevalence and dis- abling effects of OCD-SCH/SA comorbidity, only a few studies have investigated treatment strategies for this difficult-to-treat condition. The best current available treatments for noncomorbid OCD are serotonin reuptake inhibitors (SRIs) and cognitive-behavioral therapy (CBT) incorporating exposure and ritual prevention [13]. The American Psychiatric Association guidelines [13] and Po- yurovsky et al. [14] suggest treating OCD co-occurring with SCH by combining either typical or atypical antipsychotics with SRIs. However, evidence on the beneficial effect of these combinations is inconclusive [15–27]. Furthermore, an antipsychotic-SRI com- bination could produce a clinically significant pharmacokinetic drug interaction. Hence, alternative therapeutic approaches for OCD-SCH/SA are needed. The aims of this open naturalistic study were to examine adherence to and the effectiveness of ad- junctive CBT for OCD in patients with stabilized SCH/SA.

Consecutive patients seen between 1 January 2003 and 1 Janu- ary 2008 at the ‘Istituto di Psicopatologia’ in Rome were screened for eligibility. Inclusion criteria were as follows: (1) age 18–65 years; (2) meeting DSM-IV criteria for OCD and either SCH or SA as assessed by the Structured Clinical Interview for DSM-IV [28, 29]; (3) OCD of at least moderate severity [Yale-Brown Obsessive Compulsive Scale (Y-BOCS) [30, 31] total score 616], and (4) sta- bilized SCH or SA, even if symptoms were not entirely absent (Positive and Negative Symptoms Scale [32] total score ^75). The exclusion criterion was the presence of neurological conditions inducing OCD.

All patients gave written informed consent for the anonymous use of their clinical records, and a local ethical committee ap- proved the research project. Twenty-one patients (13 males, 8 fe- males) were enrolled; the mean age was 29.3 years (range 18–37). Nine patients (43%) had SCH and 12 (57%) SA. The mean duration

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of OCD was 6.8 years (range 1–16.7). The temporal onset of OCD was subsequent to SCH/SA in 11 patients (6 SCH, 5 SA), anterior in 3 SA patients and concomitant in 7 patients (3 SCH, 4 SA). Four patients presented at least one other Axis I lifetime comorbid dis- order. Pharmacological treatments for SCH/SA were chosen by the first author (A.T.) based on the patient’s clinical condition, and follow-up visits were scheduled as required, ranging from every week to every few months. CBT was conducted by 4 cognitive- behavioral psychologists with 65 years of experience in treating OCD. CBT consisted of imaginal and in vivo exposure, ritual pre- vention and/or delay, cognitive therapy and other ad hoc interven- tion used to supplement exposure and ritual prevention strategies. Patients were treated in a naturalistic setting, in the sense that manualized guidelines [33] were adapted to each patient after careful consideration of their level of insight, treatment adherence and Axis I comorbidity. Therapy sessions were scheduled flexibly and jointly by the therapist and patient. Patients received an aver- age of 4 sessions per month during the first 4 months and then continued therapy with 1–4 sessions per month. CBT duration was not determined in advance. We provided a mean of 34.3 h of therapy (range 23–41) to patients with SA and 31.1 h (range 8–40) to patients with SCH, excluding 1 patient who participated in a single session before withdrawing from the study.

Obsessive-compulsive symptoms were assessed using the Y-BOCS. The clinical severity of illness was assessed using the Clinical Global Impressions-Severity (CGI-S) scale [34] and over- all functioning using the Global Assessment of Functioning scale [35]. Scales were administered at baseline (T0) and after 6 (T1) and 12 months (T2) of CBT. The Clinical Global Impressions-Im- provement (CGI-I) scale [34] was used to evaluate improvement at T1 and T2. Schizophrenic and schizoaffective symptoms at T0 were assessed using the Positive and Negative Symptoms Scale. All assessments were conducted by the first author, who was not involved in the CBT.

The primary outcomes were adherence rate (percentage of completers) and remission rate (Y-BOCS total score !16). Second- ary outcomes were treatment response, defined as a decrease in the Y-BOCS total score from baseline to T2 625%, and a CGI-I score ^2.

One patient with SCH discontinued CBT after 1 session; 1 pa- tient with SCH discontinued before T1 and 3 patients (1 SCH, 2 SA) before T2. Of these, 3 reported that CBT was ineffective and 1 was hospitalized for an episode of psychotic exacerbation. The remaining 16 patients were still receiving CBT at T2.

Table 1 shows the results of repeated-measures ANOVA for Y-BOCS and the CGI-S and the Global Assessment of Function- ing scales. All outcome measures showed statistically significant improvements at 6 months and slower improvement afterwards. There was no differential change over time in SA versus SCH, ex- cept for a significantly greater functional improvement in SA from T0 to T1. At T2, 52% of patients (11/21) were rated as ‘much/

Table 1. Results of repeated-measures ANOVA for the intent-to-treat sample


Schizoaffective disorder

Repeated-measures ANOVA1









F, d.f., p

F, d.f., p

Y-BOCS score
Total 31.686.9 28.087.7 26.688.2 Obsession 15.784.0 14.184.8 13.484.4 Compulsion 15.883.5 13.984.0 13.184.4

30.286.9 16.382.3 13.984.8

2.880.9 51.789.4 5.580.7

25.988.5 13.584.2 12.484.6

22.788.6 11.884.3 10.884.7

28.3, 1, <0.001 15.5, 1, 0.001 15.2, 1, 0.001 17.1, 1, 0.001 34.5, 1, <0.001 11.9, 1, <0.001

6.8, 1, 0.017 5.4, 1, 0.031 7.7, 1, 0.012 2.9, 1, 0.102 4.1, 1, 0.058 7.8, 1, 0.012

Insight GAF score

CGI-S score

57.2811.0 59.7813.3

3.780.7 3.081.1 2.881.5 46.0810.8 47.7811.9 50.0812.8 5.681.0 5.281.2 5.081.3

1.981.2 4.981.2 4.481.1

Values are shown as means 8 SD (n = 21). No difference was found between mean scores in SCH and SA at baseline. In the overall sample, scores decreased significantly from T0 to T1 and from T1 to T2. There was no differential change over time in SA versus SCH, except for a significantly greater functional improvement in SA from T0 to T1. GAF = Global Assessment of Functioning.

1 The ANOVA models include the effects of time, diagnosis (SCH T1-T2.

vs. SA), diagnosis ! time and contrasts between T0-T1 and

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very much’ improved (CGI-I), 33% (7/21) were responders and 19% (4/21) were remitters.

To the best of our knowledge, this is the first CBT trial in pa- tients with OCD and SCH/SA. Our results indicate good adher- ence to CBT and a 24% dropout rate consistent with the literature for patients with OCD and without SCH/SA comorbidity (13– 36%) [36–42]. The most promising results were OCD symptom reduction and improved insight of the patients into their illness. The proportion of responders and remitters is in line with clinical trials on the efficacy of adjunctive fluvoxamine with antipsychot- ics in patients with OCD and SCH [23, 27]. However, the advan- tage of adding CBT is the absence of potential risks of psychotic exacerbation or increased aggressiveness. To determine if im- provement was stable over time, we planned a follow-up evalua- tion after the end of CBT.

Our results should be interpreted keeping in mind that the study was neither double-blind nor placebo-controlled. Also, type I error might be inflated because of the small sample size and the large number of comparisons. Despite these limitations, the pres- ent work provides useful information for clinicians planning OCD treatment in patients with SCH/SA. SRIs may be used in patients who either refuse or do not respond to CBT and, vice versa, CBT may be tried in patients who did not respond to med- ication or are at higher risk of psychotic exacerbation.



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Comorbid obsessive-compulsive disorder (OCD) in patients with schizophrenia or schizoaffective disorder is frequent (10-40%) and hard to treat. In this sub-population SRI’s are often not tolerated, to our knowledge there are no trials about the use of CBT and neurocognitive impairment is relevant. The purpose of this study is to evaluate CBT effectiveness on OCD in psychotic patients.
Seventeen patients affected by OCD and Schizophrenia (41%) or schizoaffective disorder were treated with CBT, involving exposure and ritual prevention. All patients were taking atypical antypsychotics. Obsessive Compulsive symptoms were assessed by Yale-Brown Obsessive Compulsive Scale (Y-BOCS), level of functioning by the Global Assessment of Functioing (GAF) at baseline (T0), at 6 (T1) and 12 (T2) months after starting CBT. Results 23% patients dropped out of the study. Intent-to-treat analysis showed statistically significant reduction (p<.0001) from T0 to T1 and from T1 to T2 on Y-BOCS total, obsession, compulsion and insight scores.
GAF  score also significantly improved (p<.0001) during the follow-up.
CBT is likely to be a useful treatment of OCD in patient with psychosis. Symptom reduction was clinically moderate but important with nearly all patients presenting residual symptoms.