Fatores preditores de resultados no tratamento do transtorno obsessivo-compulsivo com as terapias comportamental e cognitivo-comportamental: uma revisão sistemática

Abstract

INTRODUÇÃO: As terapias comportamental e cognitivo-comportamental reduzem os sintomas do transtorno obsessivo-compulsivo em mais de 70% dos pacientes. Entretanto, cerca de 30% não obtêm nenhuma melhora. Conhecer fatores associados a esses desfechos poderia auxiliar numa melhor indicação do tratamento, incrementando sua eficácia. MÉTODO: Foram revisados trabalhos que investigaram fatores preditivos de resultados nos tratamentos do transtorno obsessivo-compulsivo, nas fontes PubMed, PsycINFO e LILACS. Termos utilizados na busca: predictive factors OR prediction AND obsessive-compulsive disorder AND exposure response prevention OR ritual prevention OR behav* therapy OR cognitive behav* therapy, resultando em 104 artigos. As referências dos artigos foram analisadas, possibilitando maior número de trabalhos revisados. Excluíram-se artigos que utilizaram apenas farmacoterapia e aqueles que não abordavam o tema, resultando em 29 artigos. DISCUSSÃO: As variáveis demográficas parecem exercer papel indireto, destacando-se sexo masculino e ausência de companheiro(a) como fatores de pior prognóstico. Maior gravidade e início precoce dos sintomas indicariam piores resultados. O transtorno esquizotípico comórbido é potencialmente negativo. Sintomas relacionados ao colecionismo e com conteúdo sexual/religioso indicam pior prognóstico. Maior nível de insight, motivação e colaboração com o tratamento são características favoráveis. Maior intensidade da melhora e a remissão completa são preditores para a não-recaída. CONCLUSÃO: A identificação de fatores preditores de resultados está longe de ser esclarecida. É possível que múltiplos fatores, cujas associações são complexas, atuem em conjunto. Os resultados podem depender de fatores não-específicos, ainda não abordados pelos estudos. A heterogeneidade do transtorno obsessivo-compulsivo e das pesquisas e o uso associado de medicamentos dificultam o estabelecimento de conclusões mais definidas.

Level of Insight in Patients With Obsessive–Compulsive Disorder: An Exploratory Comparative Study Between Patients With “Good Insight” and “Poor Insight”

“…As suggested by some authors (67–70), the presence of sensory phenomena may predict treatment failure, which can be understood not only by its possible specific neurobiological aspects, but also by the co-occurrence of poor insight (71, 72), which can itself reduce treatment engagement and reduce the chances of an appropriate treatment response. If for psychopharmacological approaches this statement is valid, the presence of sensory phenomena and poor insight leads also to increased rates of nonresponse in psychotherapeutic therapies (39). Moritz et al reported that the presence of sensory phenomena in patients diagnosed with OCD predicts poor insight, but it depends on the type of sensory phenomenon, with special emphasis on visual and tactile phenomena (not analyzed in our study) (71).…”

“…Neuroleptics are not the first-choice treatment for OCD, but it seems to be valid as adjuvant when treating resistant or refractory OCD (83), especially atypical neuroleptics, which have augmenting synergism with selective serotonin reuptake inhibitors (SSRIs) because they also have serotonergic action (83, 84). As the CTOC sample is predominantly composed of specialized and tertiary health services, the recruitment of more severe patients, nonresponders to conventional and complex treatments (with comorbidities with tics, for example), may have biased our results, leading to a greater prevalence of the use of these specific medications in these centers (39, 42, 85). As poor insight was related to sensory phenomena, and since sensory phenomena are more prevalent in patients with OCD who also have tics (64, 86), we could speculate a “dopaminergic” modulation of “poor insight.” It could be explained by the facts that tics occur due to dopaminergic dysfunctions involving the basal nuclei, especially striatum and substantia nigra (87, 88), which may result clinically in the increased prescription of drugs with dopaminergic action, such as neuroleptics.…”

“…Instead of using only the Yale–Brown obsessive–compulsive scale (Y-BOCS) (45) item for insight, we assessed the presence and severity of insight with a specific instrument: the Brown assessment beliefs scale (BABS) (32). Thereby, according to the literature and to our clinical experience, we hypothesize that OCD patients with poor insight will present: earlier age of onset of obsessive–compulsive symptoms (OCS) (47, 48), longer duration of illness (8, 39, 48), higher prevalence of familial history of OCD (49), higher prevalence of neuroleptics prescription (50), higher prevalence of suicidality, more common presence and higher severity of specific OCS content [especially for contamination/washing/cleaning (51) and hoarding (36, 47, 52)], higher prevalence of any sensory phenomena (53), higher severity of depressive (54) and anxious symptoms, and higher prevalence of specific comorbid psychiatric disorders [especially major depression (47, 48), dysthymia (55), bipolar disorder (56), and delusional disorder (57)].…”

“…To better highlight the importance of the topic (and also to illustrate the heterogeneity of how it has been approached), 4% to 36% of OCD patients have poor or no insight about their symptoms and their pathology (8, 35–38). This poor insight subset of patients can accommodate their symptoms and take more time to seek treatment, which would associate poor insight with longer duration of illness or longer time without treatment, all of which are negative predictors for the therapeutic process of OCD, showing a worse prognosis (8, 35, 39–46).…”

Predictors of response to group cognitive-behavioral therapy in the treatment of obsessive-compulsive disorder

“…Raffin et al's. [43] and Keeley et al's. [31], proceeding systematic literature reviews focused on predictive factors of treatment results in OCD, found several studies in which factors associated with a better prognosis with BT or CBT in the treatment of OCD, either associated or not with selective serotonin reuptake inhibitors (SSRI), such as: having a partner [10,49]; greater improvement by the end of treatment [8,21,41]; younger age [21]; being employed [9]; no history of prior treatment [9]; better treatment compliance [13,41]; therapeutic alliance [32]; greater patient motivation for treatment [14,32]; and complete remission of OCS with treatment [8].…”