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Scrupulosity is a subtype of obsessive-compulsive disorder (OCD) defined by religious or moral fears. Although the relationship between personality and OCD has been extensively studied, it remains unclear how personality relates specifically to religious obsessions and scrupulous fears. In the current study, we examined the association between scrupulosity and personality characteristics, including the Five Factor Model (FFM) and obsessive-compulsive personality disorder (OCPD), in a sample of individuals with self-reported obsessive-compulsive (OC) symptoms. Seventy-nine participants completed an anonymous online survey. FFM traits did not, but OCPD traits did, explain a significant amount of variance in scrupulosity. We also replicated previous findings showing that individuals with greater OC symptoms score lower on Extraversion and higher on Neuroticism. These findings suggest that scrupulous symptoms may not be specifically linked with any of the FFM personality factors, but may be associated with OC...

Objectives: Scrupulosity is a relatively common but understudied subtype of obsessive-compulsive disorder (OCD) characterized by religious or moral fears. It is difficult to treat and frequently disabling. We examined scrupulosity as it relates to (a) treatment-seeking behavior and perceived treatment gains, (b) the perceived effect of symptoms on religious experience, and (c) conceptions of God. Method: Seventy-two individuals with scrupulous OCD (mean age = 36; 70% women) and 75 individuals with nonscrupulous OCD (mean age = 38; 81% women) completed an internet-based survey. Results: The groups did not differ on demographic variables or overall OCD severity. Compared with the nonscrupulous group, the scrupulous group was (a) more religious, (b) more likely to seek pastoral counseling, (c) less likely to seek medication treatment, and (d) more likely to report that symptoms interfered with their religious experience. Indeed, most scrupulous individuals endorsed that their symptoms interfered with their religious experience. Scrupulous individuals with a more negative concept of God experienced more severe symptoms, whereas a positive description of God was unrelated to severity of scrupulosity in this group. Nearly one in five scrupulous participants reported no religious affiliation. Conclusions: Scrupulous individuals have unique treatment-seeking preferences. Moreover, most scrupulous individuals perceive their symptoms as interfering with their religious experience. Focusing on the religious costs and benefits of scrupulous rituals might have clinical utility. Finally, scrupulous individuals with a more negative concept of God experienced more severe symptoms. Future research is necessary to evaluate whether addressing such concepts can improve treatment outcome. © 2011 Wiley Periodicals, Inc. J Clin Psychol 67:1–9, 2011.

Trichotillomania is a disorder of compulsive hair pulling that often results in alopecia. The clinical features include the pulling of hair from the scalp, eyebrows, and eyelashes, sometimes symmetrically; pubic and other bodily hair may also be plucked. The disorder is present in 0.6% of college students. The majority of sufferers who seek treatment are female, with usual age of onset between 11 and 16 years. Trichotillomania can occur in a wide variety of psychiatric disorders, and patients with the condition may be more likely to have a lifetime diagnosis of depression or an anxiety, eating, or substance abuse disorder. Although empirically derived treatment guidelines are still lacking, the current literature suggests that behavior therapy and pharmacotherapy are the most efficacious treatments for adult trichotillomania. Controlled trials with pharmacotherapy (clomipramine) have shown significant reductions in hair pulling over the short term. Controlled investigations of behavior therapy have not been conducted, but several treatment series suggest efficacy. At least three reports also suggest that behavior therapy and pharmacotherapy bring some improvement in childhood trichotillomania, although this has not been empirically studied. A case illustrating the combination of behavior therapy techniques and pharmacotherapy in the treatment of trichotillomania is presented.

Many agents that affect the brain's serotonergic system appear to be at least partially effective in the treatment of patients with obsessive-compulsive disorder. However, in this 10-week double-blind trial in which 10 patients received sertraline and nine received placebo, sertraline was ineffective according to four measures of obsessive-compulsive symptoms. The authors discuss the implications of these preliminary findings for the serotonergic theory of obsessive-compulsive disorder and the need to explore the role of other neurochemical systems in this disorder.

In 138 patients with Obsessive Compulsive Disorder, significant differences in mean age of onset were found among subtypes. Patients with obsessions only or cleaning rituals only had comparable ages of onset (age 27), while patients with checking rituals only or mixed rituals had earlier onset (age 18–19). Implications of these findings are discussed.

OBJECTIVE: The study tested the effect of comorbid posttraumatic stress disorder (PTSD) on behavior therapy outcome for obsessive-compulsive disorder (OCD). METHOD: Subjects were 15 patients with treatment-refractory OCD who were admitted consecutively to a short-term residential facility. Eight met DSM-IV criteria for comorbid PTSD. Patients participated in coached and self-directed behavior treatments of exposure and response prevention as well as in group treatments targeting specific OCD symptoms and related difficulties. Severity of OCD and depression were assessed at admission and exit. RESULTS: Patients with comorbid PTSD showed no significant improvements in OCD and depression symptoms. OCD and depression symptoms improved significantly more in patients without comorbid PTSD than in patients with comorbid PTSD. CONCLUSIONS: Behavioral treatment (with or without medication) of OCD may be adversely affected by the presence of comorbid PTSD.

Objective: It is now well documented that fluoxetine is a viable treatment option for patients with obsessive-compulsive disorder (OCD), and there is a small body of evidence indicating that monoamine oxidase inhibitors may be effective in at least a subset of patients. The authors conducted a 10-week placebo-controlled trial of these two agents in patients who met DSMIII-R criteria for OCD. Method: Sixty-four subjects were randomly assigned to receive placebo, phenelzine (60 mg/day), or fluoxetine (80 mg/day). These doses were achieved by the end of week 3 of the active phase of the study. Outcomes were assessed with standardized instruments to measure OCD, mood, and anxiety. Results: Fifty-four patients completed the study. There was a significant difference among the three treatments on one OCD scale, with fluoxetine-treated patients improving significantly more than those in the placebo or phenelzine group. A subgroup of OCD patients with symmetry obsessions did respond to phenelzine. Conclusions: This study provides no evidence to support the use of phenelzine in OCD except possibly for those patients with symmetry or other atypical obsessions. There was also no support for the hypothesis that patients with high levels of anxiety would respond preferentially to phenelzine. (Am J Psychiatry 1997; 154:1261‐1264)

Thirty-eight patients with primary obsessive-compulsive disorder participated in a 10-week, double-blind, placebo-controlled trial of the potent, selective serotonin reuptake inhibitor fluvoxamine. Fluvoxamine was significantly better than placebo on two of three measures of improvement in obsessive-compulsive symptoms. The authors also compared studies of the serotonergic agents fluvoxamine, sertraline, fluoxetine, and clomipramine and found that a greater effect size was associated with less serotonergic specificity and that some ability to affect other neurotransmitter systems may be a necessary but not sufficient requirement for antiobsessional activity. These data lend only partial support to a serotonin hypothesis of obsessive-compulsive disorder.

• We assessed 96 patients with obsessive-compulsive disorder for DSM-III personality disorder diagnoses with a standardized interview instrument (Structured Interview for the DSM-III Personality Disorders). Fifty patients (52%) met criteria for at least one personality disorder, with mixed, dependent, and histrionic personality disorders most frequently diagnosed. Compulsive personality disorder was diagnosed in only 6 patients (6%), 5 of whom had had onset of obsessive-compulsive symptoms before the age of 10 years, indicating that DSM-III compulsive personality disorder is not invariably a premorbid condition for the development of obsessive-compulsive disorder. Schizotypal personality disorder, at 5%, was found to be less common than in past samples, reflecting differences in either assessment methods or sampling.

The age of onset of agoraphobia with spontaneous panic attacks (DSM III) was studied in 100 consecutive patients. A uniform unimodal age of onset distribution was found. Mean age of onset was 24 years. Sixty-five percent of cases began in the 15–29 age group. Ninety-six percent first started before age 40 years. The finding in two other studies of a bimodal age of onset distribution may result from artifacts inherent in their small sample sizes. The age of onset of simple single phobias without spontaneous panic attacks or other psychopathology was studied in 62 consecutive monophobic patients. The age of onset in this variety of phobic disorder was evenly distributed over all age groups. No evidence was found for a facilitatory period in the development of phobias for the first decade as compared to the second or third life—although age may determine which environmental stimuli become phobic stimuli at different ages. There was a statistically significant difference between the age of onset distribution and the sex ratio in both groups of phobic disorder. The findings are consistent with the authors classification of phobic disorders, into endogenous and exogenous varieties based on the presence or absence of concurrent spontaneous panic attacks with the phobias. It is also consistent with the model that biological factors are preeminent in the genesis of endogenous phobias, while conditioning by environmental stress is preeminent in exogenous phobias.

Twenty nine obsessive-compulsive patients were evaluated for behavior therapy by the staff of our Obsessive-Compulsive Disorders (OCD) Clinic. Ten (35%) had Axis II diagnoses of Schizotypal Personality Disorder. Of those patients without an Axis II diagnosis of Schizotypal Personality Disorder, 16 (84%) improved at least moderately with either behavior therapy alone (exposure plus response prevention) or a combination of behavior therapy and pharmacotherapy. Among the schizotypal group, only one (10%) improved with the same treatments. This difference was highly significant. Implications for behavior therapy are discussed as well as suggestions for management of these patients and for future research.

This case study describes the development and use of a portable computer program to assist in behavioral treatment of obsessive compulsive disorder. A 58-year-old female with a 37-year history of compulsive checking rituals, who had mild improvement following 36 months of standard behavioral techniques and pharmacotherapy, showed improved compliance with behavioral treatments of exposure and response prevention following use of the portable computer program. Computer records indicated marked reductions in frequency of checking rituals and a 91-week follow-up indicated that treatment effects were maintained at home where the patient had resumed using the laptop computer. She had stopped using the pocket computer outside the home, and there her checking rituals had returned to baseline levels.

Behavior therapy techniques for Obsessive Compulsive Disorder (OCD) have been effective in treating this difficult anxiety disorder. This review explores the theory and underlying behavioral strategies, rebuts common misconceptions about behavior therapy, and outlines the clinical management of obsessions, cleaning rituals, checking rituals, and obsessional slowness. Predictors of treatment failure and outcome research for OCD are reviewed.

Patients with obsessive-compulsive disorder (OCD) and related syndromes often present to physicians other than psychiatrists. These patients are difficult to recognize and even more difficult to treat and the abundance of therapeutic approaches available indicates that none is clearly effective in all cases. Patients frequently present with symptoms seemingly laden with unconscious symbolism and dynamic meaning; yet psychodynamic treatments, particularly if they are loosely structured and nondirective, rarely reduce the symptoms. Behavior therapy fares much better, particularly with compulsive rituals. Likewise, electroconvulsive therapy is not regarded as useful in the treatment of OCD. There are, however, a number of modalities that may be extremely helpful in the treatment of these patients. We review somatic treatments of OCD including medications, electroconvulsive therapy, and psychosurgery.

Despite advances in the management of patients with obsessive-compulsive disorder, some remain refractory to treatment. The authors retrospectively examined characteristics of 43 treatment-resistant obsessive-compulsive patients and found that those with concomitant schizotypal personality disorder had an extremely high rate of treatment failure. Of the 29 treated nonschizotypal patients, 26 (90%) improved at least moderately; only one of 14 (7%) schizotypal patients improved. In addition, the number of schizotypal features in each patient was strongly negatively correlated with treatment outcome.

The authors describe two cases of obsessive-compulsive disorder with concomitant bipolar affective disorder. Behavior therapy consisting of in vivo exposure plus response prevention controlled the obsessive-compulsive symptoms only after the affective illness was well controlled pharmacologically.

To the Editor.— Four years ago we began an obsessive-compulsive disorders (OCD) clinic to systematically evaluate and treat patients with these difficult disorders. All patients are initially seen by a psychiatrist to evaluate their suitability for medications. Those who are unresponsive to medication or who have clear-cut rituals are also seen by a behavioral therapist. Over the last two years, 59 patients were referred to our clinic; of these, 54 met DSM-III criteria for OCD. Of the patients with OCD, 30 were male and 24 were female (mean age, 40.4 years). We observed that certain patients tended to be refractory to standard therapeutic techniques of behavior therapy (exposure plus response prevention) and medication trials. 1-3 Most of these patients seemed unusual and we had started to use the term schizoobsessive to refer to them. We retrospectively examined characteristics of these treatment-resistant patients and found a high prevalence of schizotypal personality

Five of 29 obsessive-compulsive disorder patients were dexamethasone suppression test (DST) nonsuppressors, all of whom met standard Hamilton Depression Rating scale criteria for at least mild depression. None of 24 nondepressed obsessive-compulsive disorder patients had an abnormal DST. The relationship of the DST to specificity of psychiatric diagnoses is discussed. (J Clin Psychopharmacol 1987;7:182–184)