The structure and intensity of self-reported autonomic arousal symptoms across anxiety disorders and obsessive-compulsive disorder

BACKGROUND

Heightened autonomic arousal symptoms (AAS) are assumed to be a central feature of anxiety disorders. However, it is unclear whether the magnitude and profile of AAS vary across anxiety disorders and whether heightened AAS characterises obsessive-compulsive disorder (OCD).

AIMS

We sought to determine whether the intensity and structure of AAS varied across anxiety disorders and OCD.

METHOD

A sample of 459 individuals with a primary anxiety disorder or OCD were administered the Symptom Checklist-90R. Nine items referring to prototypic AAS were included in a latent class analysis.

RESULTS

A 2-class solution (high and low AAS classes) best fitted the data. Participants comprising the high AAS class scored uniformly high across all assessed AAS symptoms. Older age and the presence of panic disorder, social anxiety disorder and generalized anxiety disorder predicted membership in the high AAS class. No OCD symptom dimension was significantly associated with membership in the high AAS class.

LIMITATION

AAS were assessed using a self-report measure and replication is needed using other methodologies.

CONCLUSIONS

These findings suggest that OCD may be sufficiently distinct from anxiety disorders and do not support subtyping of anxiety disorders on the basis of the predominant type of AAS. Therapeutic approaches that target AAS might best be applied in the treatment of panic disorder, social anxiety disorder and generalized anxiety disorder.

International prescribing practices in obsessive-compulsive disorder (OCD)

OBJECTIVES

To assess rates of psychotropic medication use in patients with obsessive-compulsive disorder (OCD) in seven different countries on five continents and to compare these with international treatment guidelines.

METHODS

Researchers in the field of OCD were invited to contribute summary statistics on the characteristics of their patients with OCD and on their incidence of psychotropic use. Consistency of summary statistics across countries was evaluated.

RESULTS

The data came from Brazil (n = 955), Italy (n = 750), South Africa (n = 555), Japan (n = 382), Australia (n = 213), India (n = 202) and Spain (n = 82). The majority (77.9%; n = 2445) of the total sample of 3139 participants received a psychotropic medication. Consistent with international guidelines, selective serotonin reuptake inhibitors (SSRIs) were most commonly used (73.5%, n = 1796), but their use ranged from 59% in Australia to 96% in Japan. Clomipramine use varied from 5% in Japan and South Africa to 26% in India and Italy. Atypical antipsychotic use ranged from 12% in South Africa to 50% in Japan.

CONCLUSIONS

Pharmacotherapy for OCD varied significantly across sites. Prospective studies are required to determine the cultural, pharmacoeconomic and pharmacogenomic factors that may play a role in the variation in prescribing practices internationally and whether these variations influence treatment outcomes. Copyright © 2016 John Wiley & Sons, Ltd.

The familiality of specific symptoms of obsessive-compulsive disorder

This study aimed to assess whether a family history of specific OCD symptoms was associated with the same OCD symptoms in study participants. Participants were sampled from the Nepean OCD study (N=206) and were assessed with the Yale-Brown Obsessive-Compulsive Scale Symptom Checklist (YBOCS-SC) and the Vancouver Obsessional Compulsive Inventory (VOCI) in order to determine their OCD symptoms. A family history screen was used to determine whether participants had a first-degree relative with a history of any of the following specific symptoms: hoarding, contamination/cleaning, symmetry/ordering, doubt/checking and/or other OCD symptoms. The characteristics of participants with a family history of a specific OCD symptom were compared to those of participants with a family history of any other OCD symptom. This was repeated for each specific OCD symptom. The roles of co-occurring tics and age of onset of OCD were also assessed. Distinct familial associations were detected for the symptoms of hoarding and contamination/cleaning. Age of onset of OCD was significantly younger in participants who reported a family history of "other" symptoms. These findings suggest that certain OCD symptom dimensions are more familial than others, which has significant implications for aetiology of OCD.

Does emotional reasoning change during cognitive behavioural therapy for anxiety?

Emotional reasoning refers to the use of subjective emotions, rather than objective evidence, to form conclusions about oneself and the world. It is a key interpretative bias in cognitive models of anxiety disorders and appears to be especially evident in individuals with anxiety disorders. However, the amenability of emotional reasoning to change during treatment has not yet been investigated. We sought to determine whether emotional reasoning tendencies change during a course of routine cognitive-behavioural therapy (CBT). Emotional reasoning tendencies were assessed in 36 individuals with a primary anxiety disorder who were seeking treatment at an outpatient clinic. Changes in anxiety and depressive symptoms as well as emotional reasoning tendencies after 12 sessions of CBT were examined in 25 individuals for whom there was complete data. Emotional reasoning tendencies were evident at pretreatment assessment. Although anxiety and depressive symptoms decreased during CBT, only one of six emotional reasoning interpretative styles (pertaining to conclusions that one is incompetent) changed significantly during the course of therapy. Attrition rates were high and there was not enough information regarding the extent to which therapy specifically focused on addressing emotional reasoning tendencies. Individuals seeking treatment for anxiety disorders appear to engage in emotional reasoning, however routine individual CBT does not appear to result in changes in emotional reasoning tendencies.

An experimental investigation of mentalization ability in borderline personality disorder

OBJECTIVE

Deficits in mentalization ability have been theorized to underlie borderline personality disorder (BPD) and have led to mentalization-based treatments. Yet there has been little empirical investigation into whether mentalization deficits do differentiate the BPD population from healthy controls, and the specific nature of these differences.

METHOD

Five pre-existing Theory of Mind (ToM) tasks that assessed simple to complex mentalization capacity in both the affective and cognitive domains were administered to the same groups of age and gender matched patients with BPD and controls. Self-report measures assessed cognitive and affective empathy and childhood trauma and abuse.

RESULTS

The BPD group did not differ significantly from the healthy control group on basic cognitive false-belief picture-sequencing tasks, or on overall accuracy when discriminating mental states from viewing images of eyes, and attributing emotions based on social events. They were, however, significantly less accurate in identifying positive mental states on the Reading the Mind in the Eyes (RME) task and showed significantly more mentalization errors on affective and cognitive understanding of faux pas (faux pas total score p<.01) and on a Joke Appreciation task (p=.01), that required integration of multiple perspectives. They also self-reported less empathic perspective taking (p<.01). Observation of patterns of performance hinted at specific underlying biases (e.g. a default tendency to use superficial black-and-white attributions to others, such as, "he is mean", when explaining behavior). It was also found that as childhood experiences of punishment increased, adulthood mentalization ability decreased on all affective ToM tasks and on the cognitive and affective components of understanding faux pas.

CONCLUSIONS

The BPD group was as capable as controls in undertaking simple mentalization. However, deficits in mentalization capacity became evident when mentalization tasks became more complex and required the integration of multiple perspectives. Increasing childhood experiences of punishment were related to decreasing mentalization ability in adulthood. Findings support the use of treatments to improve mentalization skills in BPD, however, further research is needed to better specify the nature of underlying mentalizing biases in this population.

Specificity of the Relationships Between Dysphoria and Related Constructs in an Outpatient Sample

Dysphoria has recently been conceptualized as a complex emotional state that consists of discontent and/or unhappiness and a predominantly externalizing mode of coping with these feelings. The Nepean Dysphoria Scale (NDS) was developed on the basis of this model of dysphoria and used in this clinical study to ascertain the specificity of the relationships between dysphoria and relevant domains of psychopathology. Ninety-six outpatients completed the NDS, Symptom Checklist 90-Revised (SCL-90R) and Depression, Anxiety, Stress Scales, 21-item version (DASS-21). The scores on the NDS subscales (Discontent, Surrender, Irritability and Interpersonal Resentment) and total NDS scores correlated significantly with scores on the DASS-21 scales and relevant SCL-90R subscales. Multiple regression analyses demonstrated the following: DASS-21 Depression and Stress each had unique relationships with NDS Discontent and Surrender; DASS-21 Anxiety had a unique relationship with NDS Discontent; SCL-90R Hostility and Paranoid Ideation and DASS-21 Stress each had unique relationships with NDS Irritability; and SCL-90R Paranoid Ideation and DASS-21 Stress, Depression and Anxiety each had unique relationships with NDS Interpersonal Resentment. These findings support the notion that dysphoria is a complex emotional state, with both non-specific and specific relationships with irritability, tension, depression, paranoid tendencies, anxiety, hostility and interpersonal sensitivity. Conceptual rigor when referring to dysphoria should be promoted in both clinical practice and further research.

A meta-analysis of the response of pathological hoarding to pharmacotherapy

This meta-analysis aimed to identify all studies that have assessed treatment response for pathological hoarding treated with pharmacological agents. Seven studies were identified with a total of 92 participants. Most participants had a diagnosis of obsessive-compulsive disorder. Studies assessed response to serotonin-reuptake inhibitors (SRIs); venlafaxine; methylphenidate; and augmentation of SRIs with quetiapine, minocycline and naltrexone. More than half (ER=0.58, 95% CI=0.37-0.76) of the participants treated with pharmacotherapy responded. This study encourages us to consider the use of SRIs in patients with hoarding disorder. The study also encourages more studies of pharmacotherapy for pathological hoarding, noting that these studies should use validated outcome measures that specifically assess pathological hoarding and novel agents that target the unique neurobiological correlates of pathological hoarding.

Managing obsessive compulsive disorder

Unlike obsessive compulsive personality traits or occasional repetitive habits, obsessive compulsive disorder can be highly distressing and associated with significant disability. Treatment should always be offered. Psychological interventions and selective serotonin reuptake inhibitors are first-line treatments for obsessive compulsive disorder. Patients with obsessive compulsive disorder respond to selective serotonin reuptake inhibitors at a slower rate than those with depression. The dose of a selective serotonin reuptake inhibitor can be increased at two-week intervals depending on the patient's response. Aim for doses in the higher therapeutic range. Improvements from treatment usually plateau at 12 weeks. Successful treatment should continue for at least 12 months. There is a significant risk of relapse when treatment is stopped.

Assessment and treatment of hoarding disorder

OBJECTIVES

To provide a brief selective review of the current literature regarding Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Hoarding Disorder, with an emphasis on its associated risks, assessment and management approaches.

CONCLUSIONS

Hoarding disorder is defined by clear diagnostic criteria. It can be a severe and disabling disorder that can pose significant safety risks to the individual and to others. Management is often challenging, due to the poor level of insight that people with hoarding disorder often have. Psychological approaches tend to adapt cognitive-behavioural approaches, in order to specifically target areas such as impaired decision-making and motivation. Several trials of pharmacological agents have been conducted, but the limitations of these studies call for further research.

The rites of writing papers: steps to successful publishing for psychiatrists

OBJECTIVE

To encourage psychiatrists to publish high-quality articles in peer-reviewed journals by demystifying the publishing process.

METHODS

This paper will describe the publishing process and outline key factors that ensure that publishing is an achievable goal for psychiatrists.

RESULTS

The publishing process can be long and often this is related to delays associated with obtaining reviewers and their comments. Negative reviewer comments often relate to grammatical and typographical errors, an insufficient literature review, failure to adequately discuss limitations and conclusions that are not adequately supported by the results. Authors who systematically respond to their paper's reviewer comments are usually successful in having their papers accepted. Success in publishing is usually determined by a topic that appeals to the readership of a journal, a credible methodology and a paper that is well-written.

CONCLUSIONS

Publishing is achievable for all psychiatrists providing they can write a paper that delivers a clear and concise message, are willing to address reviewer comments and that their paper is tailored to the readership of the journal.

The clinical characteristics of obsessive compulsive disorder associated with high levels of schizotypy

OBJECTIVES

This study aims to examine the characteristics of obsessive compulsive disorder (OCD) associated with high levels of schizotypy.

METHODS

Using the Schizotypal Personality Questionnaire (SPQ) with 177 individuals with OCD, patients with OCD and high levels of schizotypy (OCD-HS) were compared to patients with OCD and low levels of schizotypy (OCD-LS) on a range of clinical characteristics. Self-report and clinician-administered instruments were used. Results were adjusted for the severity of OCD symptoms, age, marital status and comorbidity using logistic regression.

RESULTS

Patients with OCD-HS were younger and less likely to have been married. OCD-HS was associated with higher rates of symmetry/order obsessions, ordering/arranging compulsions, checking compulsions, co-occurring major depression, post-traumatic stress disorder, substance use disorders and greater general psychopathology. Previously reported associations, such as higher total scores on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) were not significant when adjusted for differences in demographic variables and comorbidity.

CONCLUSIONS

Patients with OCD-HS were associated with specific OCD symptoms and comorbid conditions and may warrant a specific treatment approach.

The relationships between obsessive-compulsive symptom dimensions and cognitions in obsessive-compulsive disorder

Several studies have linked obsessive-compulsive symptoms to specific obsessive-compulsive cognitions, however methodologies have varied, and no study has determined obsessive-compulsive symptoms using the most widely used clinician rating scale, the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). Considering that almost all studies that used factor analysis to ascertain OCD symptom dimensions were based on the Y-BOCS and that self-report instruments assessing obsessive-compulsive symptoms correlate poorly with the Y-BOCS, there is a need to use the Y-BOCS to examine the relationship between obsessive-compulsive cognitions and obsessive-compulsive symptom dimensions. This study examined the relationship between five Y-BOCS-derived obsessive-compulsive symptom dimensions and the three obsessive-compulsive cognitive domains identified by the obsessive-beliefs questionnaire (OBQ). The symmetry/ordering symptom dimension was associated with increased perfectionism/intolerance of uncertainty, the unacceptable/taboo thoughts symptom dimension was associated with increased importance/control of thoughts and the doubt/checking symptom dimension was associated with increased responsibility/threat estimation. There was no statistical evidence of an association between any OBQ belief sub-scale and the hoarding symptom dimension nor the contamination/cleaning symptom dimension. The findings encourage symptom-based approaches to cognitive-behavioural therapy for some OCD symptoms and call for further research on cognitions associated with contamination/cleaning symptoms and hoarding.

The Relationship Between Cognitive Behavioral Therapy Maintenance Processes, Emotional Distress, and Positive Psychotic Symptoms: Evidence That CBT Is “Not a Quasi-Neuroleptic”

Cognitive behavioral therapy for psychosis (CBTp) has enjoyed a steep rise in popularity over the past 15 years; however, recent systematic reviews and meta-analyses have concluded that CBTp has only modest effects on psychotic syndrome outcomes and that empirical evidence of its superiority over other psychosocial treatments is poor. And although it has been argued by some prominent authors that CBTp is not designed to alleviate the “psychotic syndrome,” there is little empirical evidence linking CBTp change mechanisms with syndrome versus single-symptom outcome measures. This study investigated the relationship between CBTp change processes, beliefs about voices, and thought control strategies, with a range of outcome measures including global positive psychotic symptoms in a sample of 40 voice hearers with established diagnosis of psychotic disorder. Consistent with the assertions of Birchwood and Trower (2006), global positive symptoms were found to be generally poorly related to CBTp change processes. Conversely, these CBTp change processes were found to be generally strongly related to measures of emotional distress and some measures of single psychotic symptoms. The implications for past and future CBTp treatment outcome studies are discussed.

Predictors of the length of stay in a psychiatric emergency care centre

OBJECTIVE

This paper aims to ascertain predictors of the length of stay in a Psychiatric Emergency Care Centre (PECC).

METHODS

Demographic and clinical characteristics were recorded retrospectively via file audit in 477 patients who were admitted to a PECC within a six-month period. Associations between these variables and length of stay were analysed using logistic regression.

RESULTS

Length of stay in the PECC was predicted by medical complications arising in the PECC, absconding behaviour, diagnosis of depression and being brought in by family members. Aggression within the PECC and previous contact with mental health services predicted a shorter stay.

CONCLUSIONS

Length of stay in the PECC is predicted by a number of variables that are different from those that predict length of stay in an acute psychiatric unit. A comprehensive assessment of these variables prior to admission may decrease the length of stay in the PECC and improve efficiency of acute psychiatric services.