The putative catalytic role of higher serotonin bioavailability in the clinical response to exposure and response prevention in obsessive-compulsive disorder

Sampaio, Thiago; Lima, Cristiane; Corregiari, Fabio; Bernik, Marcio

doi:10.1590/1516-4446-2015-1721

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Brazilian Journal of Psychiatry

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Original Articles • Rev. Bras. Psiquiatr. 38 (04) • Oct-Dec 2016 • https://doi.org/10.1590/1516-4446-2015-1721 copy

The putative catalytic role of higher serotonin bioavailability in the clinical response to exposure and response prevention in obsessive-compulsive disorder

Authorship SCIMAGO INSTITUTIONS RANKINGS

Objective:

Exposure and response prevention (ERP) is effective to treat obsessive-compulsive disorder (OCD), but the lack of tolerance to the aversion nature of exposure techniques results in a high drop-out rate. There have been reports of a generic stress endurance effect of serotonin (5-HT) in the central nervous system (CNS) which might be explained by suppression of defensive fixed action patterns. Previous studies have proposed that higher baseline 5-HT concentration and slow decrease in concentration during drug treatment of OCD were predictors of good clinical response to 5-HT reuptake inhibitors. The objective of this study was to investigate whether pre-treatment platelet rich plasma (PRP) 5-HT concentration is associated with latency of treatment response and final response to an ERP protocol for obsessive-compulsive disorder (OCD).

Methods:

Thirty adult and treatment-free OCD patients were included in an 8-week, 16-session ERP protocol. 5-HT concentration was determined at baseline and after treatment. Patients with a reduction ≥30% on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) at the end of ERP were defined as responders.

Results:

A positive correlation between baseline 5-HT concentration and reduction of symptoms on the Y-BOCS was observed after 4 weeks. Baseline 5-HT concentration was not correlated with clinical response after 8 weeks of ERP, possibly due to the similar though delayed clinical response of patients with lower (compared to those with higher) baseline 5-HT concentration. Patients with higher 5-HT baseline concentration also showed more improvement in depressive symptoms with treatment.

Conclusion:

The present results partially support the hypothesis of a stress endurance effect of 5-HT in OCD patients. According to the literature, fast onset responders possibly have more or larger 5-HT containing neurons, higher endogenous 5-HT synthesis or lower monoamine oxidase activity; all these hypotheses remain to be investigated.

Behavior therapy; biological markers; stress; neurophysiology; obsessive-compulsive disorder

Session	Session content
1	A) Therapeutic contract (rules and commitments). B) Psychoeducational explanation concerning relevant OCD information. C) Rationale of behavioral treatment and ERP procedures: gradual hierarchical exposure, habituation, usage of Subjective Units of Distress Scale (SUDS). D) Completing the “List of obsessions and (mental and motor) rituals.” E) Determination of the target area (focus) for ERP. F) Homework: reading the psychoeducational material and writing “OCD-symptom weekly diary.”
2	A) Check for observations or pending issues regarding the previous session. B) Homework check and review of exposure and habituation concepts. C) Elaboration of exposure hierarchy. D) Therapist-assisted exposure to first item of hierarchy. E) Completing the “self-exposure diary” with the patient and providing guidance on how to record all out-of-session exposure exercises on the next hierarchy item. F) Homework: self-controlled exposure with self-imposed response prevention to the same item applied in the session.
3 to 15	A) Check for observations or pending issues regarding previous session. B) Check for possible symptoms to include in the “List of obsessions and (mental and motor) rituals.” C) Checking homework and evaluating if the self-exposure diary was correctly completed. D) Review of exposure hierarchy and elaboration of new items and/or focus if necessary. E) Selection of two new hierarchy items. F) Application of ERP to one or more of the selected items. G) Completing the “self-exposure diary” with the patient and providing guidance on how to record all out-of-session exposure exercises on the next hierarchy item. H) Homework: self-controlled exposure with self-imposed response prevention (ERP).
16	A) Final evaluation: preparation for monthly follow-up. B) Discussion about ways to cope with setbacks and strategies for the maintenance of goals.

	Baseline 5-HT (mg/mL)	Y-BOCS % variation (0-4)	Y-BOCS % variation (0-8)
n	26^* * One patient was removed from the baseline 5-HT sample analyses due to problems during laboratory platelet extraction. Therefore, baseline 5-HT analysis included 26 patients.	27	27
Mean	326.08	-20.70	-40.44
Standard error of mean	54.50	5.08	6.38
Standard deviation	277.90	26.43	33.16
Range	1,018.00	96.29	122.73
Minimum	62.75	-66	-100
Maximum	1,080.75	31	22.73^† † Only two patients had higher Y-BOCS scores after treatment, with 8.33 and 22.73% increases in Y-BOCS total scores.
Percentile 25	150.46	-45.45	-61.11
Median	196.05	-15.00	-36.36
Percentile 75	543.05	0.00	-15

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[1] Correspondence: Thiago Sampaio, Rua Dr. Ovídio Pires de Campos, 785, Caixa Postal 3671, CEP 05403-903, São Paulo, SP, Brazil. E-mail: thiagosa@usp.br