Symptom Presentation and Outcome of Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder

The role of avoidance in the phenomenology of obsessive-compulsive disorder

BACKGROUND

Pathologic levels of ritualistic avoidance (also known as active avoidance) are common in the clinical presentation of obsessive-compulsive disorder (OCD). Despite its clinical relevance, there has been little examination of active avoidance as a ritualistic compulsion in adults with OCD.

OBJECTIVE

The objective of this study is to determine if adults with OCD who engage in ritualistic avoidance have greater obsessive-compulsive, anxiety, and depressive symptom severity and different comorbidity patterns than adults who do not engage in ritualistic avoidance.

METHOD

Adults with OCD (n = 133) completed an evaluation that included clinician ratings of obsessive-compulsive severity; overall illness severity; and self-reported ratings of anxiety, depression, and obsessive-compulsive severity.

RESULTS

Ritualized avoidance was endorsed by greater than 25% of the sample. Avoidant subjects and, more specifically, contaminant avoidant and reading-writing avoidant subjects presented with elevated levels of obsessive-compulsive symptom severity and greater overall clinical severity than comparison patients who did not engage in each respective avoidance ritual.

CONCLUSIONS

Patients who engage in ritualized avoidance exhibited greater obsessive-compulsive symptom severity than patients who did not. These findings suggest that ritualized avoidance functions as a compulsion for adults with OCD and that avoidance should receive careful consideration in assessment and treatment.

Group cognitive-behavioral therapy versus selective serotonin reuptake inhibitors for obsessive-compulsive disorder: a practical clinical trial

Clinical effectiveness of group cognitive-behavioral therapy (GCBT) versus fluoxetine in obsessive-compulsive disorder outpatients that could present additional psychiatric comorbidities was assessed. Patients (18-65 years; baseline Yale-Brown Obsessive-Compulsive-Scale [Y-BOCS] scores ≥ 16; potentially presenting additional psychiatric comorbidities) were sequentially allocated for treatment with GCBT (n=70) or fluoxetine (n=88). Mean Y-BOCS scores decreased by 23.13% in the GCBT and 21.54% in the SSRI groups (p=0.875). Patients presented a mean of 2.7 psychiatric comorbidities, and 81.4% showed at least one additional disorder. A reduction of at least 35% in baseline Y-BOCS scores and CGI ratings of 1 (much better) or 2 (better) was achieved by 33.3% of GCBT patients and 27.7% in the SSRI group (p=0.463). The Y-BOCS reduction was significantly lower in patients with one or more psychiatric comorbidities (21.15%, and 18.73%, respectively) than in those with pure OCD (34.62%; p=0.034). Being male, having comorbidity of Major Depression, Social Phobia, or Dysthymia predicted a worse response to both treatments. Response rates to both treatments were similar and lower than reported in the literature, probably due to the broad inclusion criteria and the resulting sample more similar to the real world population.

Prevalence and clinical characteristics of mental rituals in a longitudinal clinical sample of obsessive-compulsive disorder

BACKGROUND

Obsessive-compulsive disorder (OCD) is a chronic and debilitating anxiety disorder associated with significant impairment in quality of life and functioning. Research examining the differences in clinical correlates and treatment response associated with different obsessions in OCD has yielded important findings underscoring the heterogeneous nature of this disorder. To date, most of this research has focused on differences associated with primary obsessions, and little attention has been paid to the clinical utility of studying how compulsive symptoms affect clinical course. Virtually no systematic research has explored the clinical characteristics of one understudied symptom presentation, mental rituals, and what impact this primary symptom has on severity and course of illness. Mental rituals, or compulsions without overt signs, represent unique clinical challenges but often go understudied for numerous methodological and clinical reasons.

METHODS

In this study, we explored the impact of primary mental rituals on clinical severity and chronicity in a large, longitudinal sample of OCD patients (N = 225) over 4 years.

RESULTS

Mental rituals were a primary presenting symptom for a sizable percentage of the sample (12.9%). Primary mental rituals were associated with greater clinical severity and lower functioning at intake, as well as a more chronic course of illness, as participants with primary mental rituals spent nearly 1 year longer in full DSM-IV criteria episodes over the 4-year follow-up interval than OCD patients without mental rituals.

CONCLUSIONS

These results suggest that mental rituals are uniquely impairing and highlight the need for further empirical exploration and consideration in treatment.

Group cognitive-behavioral therapy for hoarding disorder: an open trial

Although cognitive-behavioral therapy (CBT) appears to be a promising treatment approach for hoarding disorder, treatment to date has been quite labor intensive. The goal of this study, therefore, was to assess the potential effectiveness of group CBT for hoarding, without home visits by the clinician. Forty-five individuals with hoarding disorder enrolled in either a 16 or 20 session program of group CBT; 30 (67%) completed treatment. Using mixed-effects models to account for missing data, we report data from 35 (78%) participants who provided enough data for analysis. Participants demonstrated significant improvements in hoarding symptoms, as well as symptoms of depression and anxiety, and quality of life. Improvements in hoarding symptoms were comparable to two published clinical trials on individual CBT for hoarding disorder. Results of this study suggest that group CBT for hoarding, without home discarding sessions by the clinician, may be an effective treatment option with the potential advantage of increasing treatment access by reducing clinician burden and cost of treatment.

Termination of washing compulsions: a problem of internal reference criteria or 'not just right' experience?

Recent research suggests that obsessive-compulsive washers are more likely than individuals without washing compulsions to use conscious, internal reference criteria when deciding when to terminate compulsions (Wahl, Salkovskis, & Cotter, 2008). An alternative view is that they possess tendencies towards non-cognitive, automatic 'not just right' experiences (NJREs) that influence compulsion duration. The current study sought to investigate the latter explanation using valid behavioral tasks. Non-clinical participants (N=133) completed self-report measures, immersed their hands in a dirt mixture, and afterwards were allowed to wash their hands. Additionally, a subset of participants completed an in vivo assessment of NJRE using a pile of clutter. Total number and intensity of NJREs were predictive of hand-washing duration. Additionally, affective response to the clutter was uniquely predictive of hand-washing duration when controlling for pre-wash anxiety. These results suggest that internal reference criteria as well as NJREs may influence compulsive washing, though the former may be a consequence of the latter.

Myth of the pure obsessional type in obsessive--compulsive disorder

BACKGROUND

Several studies have identified discrete symptom dimensions in obsessive-compulsive disorder (OCD), derived from factor analyses of the individual items or symptom categories of the Yale-Brown Obsessive-Compulsive Scale Symptom Checklist (YBOCS-SC). This study aims to extend previous work on the relationship between obsessions and compulsions by specifically including mental compulsions and reassurance-seeking. Because these compulsions have traditionally been omitted from prior factor analytic studies, their association to what have been called "pure obsessions" may have been overlooked.

METHOD

Participants (N = 201) were recruited from two multi-site randomized clinical treatment trials for OCD. The YBOCS-SC was used to assess OCD symptoms, as it includes a comprehensive list of obsessions and compulsions, arranged by content category. Each category was given a score based on whether symptoms were present and if the symptom was a primary target of clinical concern, and a factor analysis was conducted. Mental compulsions and reassurance-seeking were considered separate categories for the analysis.

RESULTS

Using an orthogonal geomin rotation of 16 YBOCS-SC categories/items, we found a five-factor solution that explained 67% of the total variance. Inspection of items that composed each factor suggests five familiar constructs, with mental compulsions and reassurance-seeking included with sexual, aggressive, and religious obsessions (unacceptable/taboo thoughts).

CONCLUSIONS

This study suggests that the concept of the "pure obsessional" (e.g., patients with unacceptable/taboo thoughts yet no compulsions) may be a misnomer, as these obsessions were factorially associated with mental compulsions and reassurance-seeking in these samples. These findings may have implications for DSM-5 diagnostic criteria.

Functions of compulsions in obsessive-compulsive disorder

OBJECTIVES

The key function of compulsions in obsessive-compulsive disorder (OCD) is to alleviate anxiety or distress caused by the obsessions, but compulsions may also have other functions. The main aim of this study was to systematically ascertain what motivates individuals with OCD to perform compulsions.

METHOD

A total of 108 adults with OCD were assessed with the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and the Functions of Compulsions Interview. The latter instrument elicits the functions of identified compulsions.

RESULTS

The functions of 218 compulsions were identified. The mean number of functions per compulsion in the whole sample was 2.94 and the vast majority of compulsions (85.3%) were performed for more than one reason. The total number of functions of compulsions endorsed for the three main compulsions correlated with Y-BOCS total scores (r = 0.37, p < 0.001). Compulsions were most frequently performed automatically and to decrease distress or anxiety, but there was substantial variation, depending on the type of compulsion. Hoarding was often performed for reasons not related to any other compulsion (involving a perceived need for collected objects), whereas ordering/symmetry/repeating compulsions were frequently performed to achieve a 'just right' feeling. Checking was frequently performed because of the belief that something bad or unpleasant would happen if one failed to check; washing/cleaning compulsions were most frequently performed to decrease distress or anxiety and automatically, and mental compulsions were performed automatically far more often than for other reasons.

CONCLUSIONS

The majority of compulsions have more than one function and they are often performed automatically. The finding of different functions of compulsions in different types of compulsions provides some support to the subtyping of OCD on the basis of obsessions and compulsions. Identifying functions of compulsions allows better understanding of the functional relationship between obsessions and compulsions, which may have implications for cognitive-behavioural therapy of OCD.

Sexual orientation obsessions in obsessive-compulsive disorder: prevalence and correlates

Sexual obsessions are a common symptom of obsessive-compulsive disorder (OCD) that may be particularly troubling to patients. However, little research has examined concerns surrounding sexual orientation, which includes obsessive doubt about one's sexual orientation, fears of becoming homosexual, or fears that others might think one is homosexual. The present study reports rates and related characteristics of individuals with sexual orientation obsessions in a clinical sample. Participants from the DSM-IV Field Trial (n=409; Foa et al., 1995) were assessed with the Yale-Brown Obsessive Compulsive Symptom Checklist and Severity Scale (YBOCS). We found that 8% (n=33) reported current sexual orientation obsessions and 11.9% (n=49) endorsed lifetime symptoms. Patents with a history of sexual orientation obsessions were twice as likely to be male than female, with moderate OCD severity. Time, interference, and distress items from the YBOCS obsessions subscale were significantly and positively correlated with a history of obsessions about sexual orientation. Avoidance was positively correlated at a trend level (p=0.055). Obsessions about sexual orientation may be associated with increased distress, interference, and avoidance, which may have unique clinical implications. Considerations for diagnosis and treatment are discussed.

Symptom dimensions in obsessive-compulsive disorder: from normal cognitive intrusions to clinical obsessions

Cognitive behavioral models of obsessive-compulsive disorder (OCD) assume continuity between normal obsessional intrusive thoughts (OITs) and obsessions. However, this assumption has recently been criticized. This article examines this issue using a new instrument (the Obsessional Intrusive Thoughts Inventory, INPIOS) specifically designed to assess the frequency and content of 48 OITs, which was completed by 734 community subjects and 55 OCD patients. Confirmatory factor analysis suggests six first-order factors included in two second-order factors, one containing aggressive, sexual, religious, immoral and repugnant OITs, and the other containing contamination, doubts and checking, symmetry and order, and superstition OITs. This structure integrates the research on OC symptoms and OITs. The INPIOS showed excellent known-groups validity, and it adequately represented obsessions as well as OITs. OCD and community subjects experience OITs representative of all types of obsessional contents. The dimensional structure is discussed in terms of OIT/obsessive-compulsive symptom structures currently proposed.

Predictors of treatment outcome in modular cognitive therapy for obsessive-compulsive disorder

BACKGROUND

The present study sought to identify predictors of outcome for a comprehensive cognitive therapy (CT) developed for patients with obsessive-compulsive disorder (OCD).

METHODS

Treatment was delivered over 22 sessions and included standard CT methods, as well as specific strategies designed for subtypes of OCD including religious, sexual, and other obsessions. This study of 39 participants assigned to CT examined predictors of outcomes assessed on the Yale-Brown Obsessive Compulsive Scale. A variety of baseline symptom variables were examined as well as treatment expectancy and motivation.

RESULTS

Findings indicated that participants who perceived themselves as having more severe OCD at baseline remained in treatment but more severe symptoms were marginally associated with worse outcome for those who completed therapy. Depressed and anxious mood did not predict post-test outcome, but more Axis I comorbid diagnoses (mainly major depression and anxiety disorders), predicted more improvement, as did the presence of sexual (but not religious) OCD symptoms, and stronger motivation (but not expectancy). A small rebound in OCD symptoms at 1-year follow-up was significantly predicted by higher scores on personality traits, especially for schizotypal (but not obsessive-compulsive personality) traits.

CONCLUSIONS

Longer treatment may be needed for those with more severe symptoms at the outset. CT may have positive effects not only on OCD symptoms but also on comorbid depressive and anxious disorders and associated underlying core beliefs. Findings are discussed in light of study limitations and research on other predictors.

Cognitive-behavioral therapy for hoarding in the context of contamination fears

Difficulty discarding and excessive acquiring can be treated using specialized cognitive-behavioral treatment that includes motivational interviewing, skills training, practice sorting and discarding, and cognitive restructuring. Early psychotherapy efforts to treat hoarding have proved less effective than this combination of methods targeted at the characteristic features of hoarding. Treatment strategies are illustrated through a case example of a woman struggling with both hoarding and contamination concerns.

Inattention, but not OCD, predicts the core features of hoarding disorder

Hoarding Disorder (HD), defined as the acquisition of and failure to discard large volumes of possessions, resulting in clutter that precludes normal use of living spaces, is a common and debilitating condition. Although hoarding has historically been conceptualized as a variant of obsessive-compulsive disorder (OCD), increasing evidence suggests that hoarding might be more closely associated with the symptoms of attention deficit-hyperactivity disorder (ADHD). The aim of the present study was to clarify the relationship between the core features of hoarding (clutter, difficulty discarding, acquiring), OCD symptoms, and ADHD symptoms. HD (N = 39), non-hoarding OCD (N = 26), and healthy control (N = 36) participants underwent careful diagnostic interviewing and completed standardized self-report measures of the core features of hoarding (clutter, difficulty discarding, acquiring), OCD symptoms, negative affect, and the inattentive and hyperactive/impulsive symptoms of ADHD. Multiple linear regressions demonstrated that after controlling for global negative affect, OCD symptoms did not significantly predict any of the core features of HD. Conversely, the inattentive (but not hyperactive/impulsive) symptoms of ADHD significantly predicted severity of clutter, difficulty discarding, and acquiring. These results challenge current conceptualizations of hoarding as a subtype of OCD, and suggest an association with neurocognitive impairment.

Adding motivational interviewing and thought mapping to cognitive-behavioral group therapy: results from a randomized clinical trial

OBJECTIVE

Recent factor-analytic studies of obsessive-compulsive disorder identified consistent symptom dimensions. This study was designed in order to observe which obsessive compulsive symptom dimensions could be changed by adding two individual sessions of motivational interviewing and thought mapping of cognitive-behavioral group therapy using a randomized clinical trial.

METHOD

Forty outpatients with a primary diagnosis of obsessive-compulsive disorder were randomly assigned to receive cognitive-behavioral group therapy (control group) or motivational interviewing+thought mapping plus cognitive-behavioral group therapy. To evaluate changes in symptom dimensions, the Dimensional Yale-Brown Obsessive-Compulsive Scale was administered at baseline and after treatment.

RESULTS

At post-treatment, there were statistically significant differences between cognitive-behavioral group therapy and motivational interviewing+thought mapping+cognitive behavioral group therapy groups in the mean total Dimensional Yale-Brown Obsessive-Compulsive Scale score, and in the contamination and aggression dimension score. Hoarding showed a statistical trend towards improvement.

CONCLUSION

These findings suggest that adding motivational interviewing+thought mapping to cognitive-behavioral group therapy can facilitate changes and bring about a decrease in the scores in different obsessive-compulsive disorder symptom dimensions, as measured by the Dimensional Yale-Brown Obsessive-Compulsive Scale. Nonetheless, additional trials are needed to confirm these results.

Treatment of Sexual-Orientation Obsessions in Obsessive-Compulsive Disorder Using Exposure and Ritual Prevention

Presented is a case report of exposure and ritual prevention (EX/RP) therapy administered to a 51-year-old, White, heterosexual male with sexual-orientation obsessions in obsessive-compulsive disorder (OCD). The patient had been previously treated with pharmacotherapy, resulting in inadequate symptom reduction and unwanted side effects. OCD symptoms included anxiety about the possibility of becoming gay, mental reassurance, and avoidance of other men, which resulted in depressive symptoms and marital distress. The patient received 17 EX/RP sessions, administered twice per week. The effect of treatment was evaluated using standardized rating instruments and self-monitoring by the patient. OCD symptoms on the Yale-Brown Obsessive Compulsive Scale (YBOCS) fell from 24 at intake to 3 at posttreatment and to 4 at a 6-week follow-up, indicating minimal symptoms. Improvement also occurred in mood, quality of life, and social adjustment. Issues concerning the assessment and treatment of homosexuality-themed obsessions in OCD are highlighted and discussed.

Distress From Sexual Thoughts: Do Religiosity, Emotions, and Thought Appraisal Matter?

Sexually intrusive thoughts (SITs) are commonly experienced; yet, there is a paucity of research on distress related to them. Given that the content is similar for intrusive thoughts and obsessions, examining factors related to obsessions in obsessive-compulsive disorder (e.g., thought appraisal and relationships to emotions) may help explain distress from SITs in nonclinical populations. Differences in affective experiences and religiosity may also explain variations in distress from SITs. Nonclinical participants (N = 291) completed questionnaires about frequency of, and distress from, SITs, thought appraisal, beliefs about sexual desire, and emotions. Distress from SITs was correlated with thought appraisal and beliefs about sexual desire, but not with religiosity. In regression analyses, beliefs about sexual desire and the frequency of SITs each predicted distress from SITs. Although thought appraisal is often implicated in obsessive-compulsive symptoms, these results indicate that beliefs about emotions may have a greater impact on distress.

Hoarding among patients seeking treatment for anxiety disorders

The aim of the present study was to examine the prevalence of hoarding symptoms among individuals presenting for treatment of anxiety symptoms. Participants included 130 adults who were seeking treatment at an outpatient anxiety disorders clinic between January 2004 and February 2006. During their initial assessment, participants (31 with panic disorder, 15 specific phobia, 27 social phobia, 36 obsessive-compulsive disorder, 21 generalized anxiety disorder, mean age 37 years, 57% female, 88% White) completed the Saving Inventory-Revised, a self-report measure of hoarding symptoms, and several measures of anxiety symptoms, depressive symptoms, and functional impairment. Approximately 12-25% of anxious patients reported significant hoarding symptoms. Patients diagnosed with generalized anxiety disorder and obsessive-compulsive disorder were more likely to report significant hoarding symptoms than were those with panic disorder or specific phobia. Hoarding symptoms were positively correlated with trait anxiety, depressive symptoms, and functional impairment. These findings suggest that hoarding symptoms may be associated with anxiety disorders other than obsessive-compulsive disorder. The findings further suggest that hoarding symptoms may be underreported by anxious populations since typical intake assessments do not include specific questions about hoarding and individuals with hoarding symptoms may be unlikely to spontaneously report them.

Cognitive and Clinical Characteristics of Sexual and Religious Obsessions

Sexual and religious obsessions are often grouped together as unacceptable thoughts, symptoms of obsessive-compulsive disorder hypothesized to be maintained by maladaptive beliefs about the importance and control of thoughts. Although there is empirical justification for this typology, there are several reasons to suspect that sexual and religious obsessions may differ with respect to associated obsessional beliefs and personality traits. In this study, we examined the associations between sexual and religious obsessions (separately) and (a) putatively obsessional cognitive styles, especially beliefs about the importance and control of thoughts, and responsibility, (b) obsessive-compulsive personality traits, and (c) schizotypal personality traits. Whereas sexual obsessions were predicted only by increased beliefs about the importance and control of thoughts, and contamination obsessions were predicted only by inflated responsibility appraisals and threat estimation, religious obsessions were independently predicted by both of these constructs. In addition, only religious obsessions were related to self-reported obsessive-compulsive personality traits. Researchers and clinicians should be cognizant of potentially important distinctions between sexual and religious obsessions, and the possibility that scrupulous OCD shares processes with both autogenous and reactive presentations.

Nonverbal memory and organizational dysfunctions are related with distinct symptom dimensions in obsessive-compulsive disorder

Recent acceptance that obsessive-compulsive disorder (OCD) represents a heterogeneous phenomenon has underscored the need for dimensional approaches to this disorder. However little is known about the relation between neuropsychological functions and symptom dimensions. The purpose of this study was to identify the cognitive deficits correlated with specific symptom dimensions. Thirteen categories in the Yale-Brown Obsessive Compulsive Scale symptom checklist from 144 patients with OCD were analyzed by principal component analysis. Correlations between identified symptom dimensions and neuropsychological functioning, measured by the Boston Qualitative Scoring System, were analyzed. Five factors or dimensions were identified: contamination/cleaning, hoarding, symmetry/ordering, obsessions/checking, and repeating/counting. Dysfunctions in nonverbal memory and organizational strategies were related to the symmetry/ordering dimension and the obsessions/checking dimension, respectively. The results of the present study support a transculturally stable symptom structure for OCD. They also suggest the possibility that nonverbal memory dysfunction and organizational impairment are mediated by distinct obsessive-compulsive dimensions.

Moderators and predictors of response to cognitive-behavioral therapy augmentation of pharmacotherapy in obsessive-compulsive disorder

BACKGROUND

Cognitive-behavioral therapy (CBT) consisting of exposure and response prevention (EX/RP) is efficacious as a treatment for obsessive-compulsive disorder (OCD). However, about half of patients have a partial or poor response to EX/RP treatment. This study examined potential predictors and moderators of CBT augmentation of pharmacotherapy, to identify variables associated with a poorer response to OCD treatment.

METHOD

Data were drawn from a large randomized controlled trial that compared the augmenting effects of EX/RP to stress management training (SMT; an active CBT control) among 108 participants receiving a therapeutic dose of a serotonin reuptake inhibitor (SRI). Stepwise regression was used to determine the model specification.

RESULTS

Pretreatment OCD severity and gender were significant moderators of outcome: severity affected SMT (but not EX/RP) outcome; and gender affected EX/RP (but not SMT) outcome. Adjusting for treatment type and pretreatment severity, significant predictors included greater co-morbidity, number of past SRI trials, and lower quality of life (QoL). Significant moderators, including their main-effects, and predictors accounted for 37.2% of the total variance in outcome, comparable to the impact of treatment type alone (R2=30.5%). These findings were replicated in the subgroup analysis of EX/RP alone (R2=55.2%).

CONCLUSIONS

This is the first randomized controlled study to examine moderators and predictors of CBT augmentation of SRI pharmacotherapy. Although effect sizes for individual predictors tended to be small, their combined effect was comparable to that of treatment. Thus, future research should examine whether monitoring for a combination of these risk factors and targeting them with multi-modular strategies can improve EX/RP outcome.

Compulsive hoarding

Compulsive hoarding is a chronic and debilitating condition that represents a significant public health concern. Hoarding is characterized by four key elements: difficulty discarding, excessive acquiring, clutter, and distress and impairment due to hoarding. This article reviews the current literature on compulsive hoarding, including its course and features, comorbidity, nosology, clinical presentation, and treatment response. The authors describe the cognitive-behavioral therapy model and treatment of hoarding, including a case presentation of a cognitive behavioral group treatment of compulsive hoarding.

Compulsive hoarding: current controversies and new directions

Compulsive hoarding is a disabling psychological disorder characterized by excessive collecting and saving behavior. This article reviews four key areas of recent advances in hoarding research. First, we provide an overview of the evolving controversy regarding the diagnostic status of hoarding, highlighting accumulating evidence that it may be best conceptualized as a separate syndrome. Second, we describe advances in our understanding of the epidemiology, course, and demographic features of compulsive hoarding. Third, we review the latest findings regarding possible neuropsychological correlates of the disorder. Finally, we discuss ongoing progress and future directions related to the clinical management of compulsive hoarding.

Cognitive therapy for autogenous and reactive obsessions: clinical and cognitive outcomes at post-treatment and 1-year follow-up

This study provides data about the differential effectiveness of cognitive therapy (CT) for obsessive-compulsive disorder (OCD) symptom presentation. Two OCD manifestations, autogenous and reactive, are considered. Seventy OCD patients started CT; 81.40% completed it and 72.85% were available 1 year later. Fifteen of the 57 treatment completers had autogenous obsessions, whereas 33 had reactive obsessions. Nine patients had both obsession modalities. Reactive patients were more severe, as they scored higher on thought suppression and on the dysfunctional beliefs of intolerance to uncertainty and perfectionism. Autogenous patients scored higher on the over-importance of thoughts beliefs. Although CT was effective in reducing OCD severity and the ascription to dysfunctional beliefs and neutralizing strategies in both the autogenous and the reactive patients, a significantly better outcome was observed for the autogenous patients, both at post-treatment (with 73.33% recovering versus 33.33% for reactives) and 1 year later.

Scrupulosity: a unique subtype of obsessive-compulsive disorder

The earliest descriptions of obsessive-compulsive disorder (OCD) were religious, as was the understanding of their origins. With the emancipation, religion in OCD was relegated to its status today: a less common symptom of OCD in most Western societies known as scrupulosity. The frequency of scrupulosity in OCD varies in the literature from 0% to 93% of cases, and this variability seems predicated on the importance of religious belief and observance in the community examined. Despite the similarities between religious ritual and compulsions, the evidence to date that religion increases the risk of the development of OCD is scarce. Scrupulosity is presented as a classic version of OCD, with obsessions and compulsions, distress, and diminished functioning similar to those of other forms of OCD. The differentiation between normal religiosity and scrupulosity is presented, and the unique aspects of cognitive-behavioral therapy in treating scrupulosity, especially in religious populations, are reviewed.

A 2-year prospective follow-up study of the course of obsessive-compulsive disorder

BACKGROUND

Surprisingly little is known about the long-term course of obsessive-compulsive disorder (OCD). This prospective study presents 2-year course findings, as well as predictors of course, from the Brown Longitudinal Obsessive Compulsive Study, the first comprehensive prospective investigation of the observational course of OCD in a large clinical sample.

METHOD

The sample included 214 treatment-seeking adults with DSM-IV OCD at intake who identified OCD as the most problematic disorder over their lifetime. Subjects were enrolled from 2001-2004. At annual interviews, data on weekly OCD symptom status were obtained using the Longitudinal Interval Follow-Up Evaluation. Probabilities of full remission and partial remission over the first 2 years of collected data and potential predictors of remission were examined.

RESULTS

The probability of full remission from OCD was 0.06, and the probability of partial remission was 0.24. Of the 48 subjects whose OCD symptoms partially or fully remitted, only 1 relapsed within the first 2 years. Earlier age at onset of OCD, greater severity of symptoms at intake, older age at intake, and being male were associated with a decreased likelihood of remission. Insight, diagnostic comorbidity, and treatment were not found to be associated with the likelihood of achieving full or partial remission.

CONCLUSIONS

Though one-quarter of the sample had periods of subclinical OCD symptoms during the prospective period, full remission was rare, consistent with the view of OCD as a chronic and persistent illness. Age at onset, OCD symptom severity, current age, and sex emerged as potent predictors of course.

A brief interview for assessing compulsive hoarding: the Hoarding Rating Scale-Interview

This article describes the development and validation of the Hoarding Rating Scale-Interview (HRS-I), a brief (5-10 min) five-item semi-structured interview that assesses the features of compulsive hoarding (clutter, difficulty discarding, acquisition, distress and impairment). Trained interviewers administered the HRS-I to 136 adults (73 compulsive hoarding, 19 OCD, 44 non-clinical controls) along with a battery of self-report measures. An initial assessment was conducted in the clinic, and a second assessment was conducted in participants' homes. The HRS-I showed high internal consistency and reliability across time and context. The HRS-I clearly differentiated hoarding and non-hoarding participants, and was strongly associated with other measures of hoarding. It is concluded that the HRS-I is a promising measure for determining the presence and severity of compulsive hoarding.

Obsessive-compulsive disorder: a review of the diagnostic criteria and possible subtypes and dimensional specifiers for DSM-V

BACKGROUND

Since the publication of the DSM-IV in 1994, research on obsessive-compulsive disorder (OCD) has continued to expand. It is timely to reconsider the nosology of this disorder, assessing whether changes to diagnostic criteria as well as subtypes and specifiers may improve diagnostic validity and clinical utility.

METHODS

The existing criteria were evaluated. Key issues were identified. Electronic databases of PubMed, ScienceDirect, and PsycINFO were searched for relevant studies.

RESULTS

This review presents a number of options and preliminary recommendations to be considered for DSM-V. These include: (1) clarifying and simplifying the definition of obsessions and compulsions (criterion A); (2) possibly deleting the requirement that people recognize that their obsessions or compulsions are excessive or unreasonable (criterion B); (3) rethinking the clinical significance criterion (criterion C) and, in the interim, possibly adjusting what is considered "time-consuming" for OCD; (4) listing additional disorders to help with the differential diagnosis (criterion D); (5) rethinking the medical exclusion criterion (criterion E) and clarifying what is meant by a "general medical condition"; (6) revising the specifiers (i.e., clarifying that OCD can involve a range of insight, in addition to "poor insight," and adding "tic-related OCD"); and (7) highlighting in the DSM-V text important clinical features of OCD that are not currently mentioned in the criteria (e.g., the major symptom dimensions).

CONCLUSIONS

A number of changes to the existing diagnostic criteria for OCD are proposed. These proposed criteria may change as the DSM-V process progresses.

Should an obsessive-compulsive spectrum grouping of disorders be included in DSM-V?

The obsessive-compulsive (OC) spectrum has been discussed in the literature for two decades. Proponents of this concept propose that certain disorders characterized by repetitive thoughts and/or behaviors are related to obsessive-compulsive disorder (OCD), and suggest that such disorders be grouped together in the same category (i.e. grouping, or "chapter") in DSM. This article addresses this topic and presents options and preliminary recommendations to be considered for DSM-V. The article builds upon and extends prior reviews of this topic that were prepared for and discussed at a DSM-V Research Planning Conference on Obsessive-Compulsive Spectrum Disorders held in 2006. Our preliminary recommendation is that an OC-spectrum grouping of disorders be included in DSM-V. Furthermore, we preliminarily recommend that consideration be given to including this group of disorders within a larger supraordinate category of "Anxiety and Obsessive-Compulsive Spectrum Disorders." These preliminary recommendations must be evaluated in light of recommendations for, and constraints upon, the overall structure of DSM-V.

The impact of symptomatic hoarding in OCD and its treatment

BACKGROUND

The value of defining subtypes in obsessive compulsive disorder (OCD) has become an important issue for recent debate. Probably the most robust example of subtyping is the identification of hoarding as being different both in terms of psychopathology and response to treatment.

AIMS

To identify differences in psychopathology and treatment response in OCD patients with and without additional hoarding symptoms.

METHOD

Patients who had undertaken CBT for OCD were selected as falling into either a high or a low hoarding group. The high hoarding group (n = 18) was selected on the basis of a high score on the hoarding subscale of a self-report measure of OCD symptoms in addition to reaching clinician judged "threshold" on the hoarding item of the Obsessive Compulsive Personality Disorder (OCPD) SCID-II module. The low hoarding group (n = 20) was selected on the basis of a low score on the hoarding subscale and a clinician judgement that the hoarding item of the OCPD SCID-II module was "absent".

RESULTS

On some measures of pre-treatment psychopathology, patients with OCD with hoarding symptoms were more severely affected than those without hoarding symptoms. It was found that there was no difference in eventual treatment outcome between the two groups, although there was some evidence that the hoarding group showed greater symptom decreases.

CONCLUSIONS

The presence of hoarding symptoms does not negatively impact on the treatment of OCD.

Comorbidity of obsessive-compulsive disorder with obsessive-compulsive personality disorder: Does it imply a specific subtype of obsessive-compulsive disorder?

The present study examined whether the comorbidity of obsessive-compulsive personality disorder (OCPD) and obsessive-compulsive disorder (OCD) constitute a specific subtype of OCD. The study sample consisted of 146 consecutive outpatients with a DSM-IV diagnosis of OCD. Diagnoses were established using MINI, IPDE, YBOCS and YBOCS-SC. OCD patients with comorbid OCPD were compared with OCD patients without OCPD on various sociodemographic and clinical variables. Almost one third of the OCD subjects met criteria for comorbid OCPD. OCD+OCPD patients had a significantly earlier age at onset of initial OC symptoms, earlier age at onset of OCD and more obsessions and compulsions than pure obsessions compared to the patients with OCDOCPD. OCD+OCPD patients also had a higher rate of comorbidity with avoidant personality disorder and showed more impairment in global functioning. There were not differences between the two sub-groups on severity of OCD symptoms and also on type of OCD onset. Our results indicate that the comorbidity of OCD with OCPD is associated with a number of specific clinical characteristics of OCD. These findings in conjunction with of current clinical, family and genetic studies provide some initial evidence that OCD comorbid with OCPD constitute a specific subtype of OCD.

Waitlist-controlled trial of cognitive behavior therapy for hoarding disorder

OBJECTIVE

This study investigated a multicomponent cognitive behavioral treatment (CBT) for hoarding based on a model proposed by Frost and colleagues and manualized in Steketee and Frost (2007).

METHOD

Participants with clinically significant hoarding were recruited from the community and a university-based anxiety clinic. Of the 46 patients randomly assigned to CBT or waitlist (WL), 40 completed the 12-week assessment and 36 completed 26 sessions. Treatment included education and case formulation, motivational interviewing, skills training for organizing and problem solving, direct exposure to nonacquiring and discarding, and cognitive therapy. Measures included the Saving Inventory-Revised (self-report), Hoarding Rating Scale-Interview, and measures of clinical global improvement. Between group repeated measures analyses using general linear modeling examined the effect of CBT versus WL on hoarding symptoms and moodstate after 12 weeks. Within group analyses examined pre-post effects for all CBT participants combined after 26 sessions.

RESULTS

After 12 weeks, CBT participants benefited significantly more than WL patients on hoarding severity and mood with moderate effect sizes. After 26 sessions of CBT, participants showed significant reductions in hoarding symptoms with large effect sizes for most measures. At session 26, 71% of patients were considered improved on therapist clinical global improvement ratings and 81% of patients rated themselves improved; 41% of completers were clinically significantly improved.

CONCLUSIONS

Multicomponent CBT was effective in treating hoarding. However, treatment refusal and compliance remain a concern, and further research with independent assessors is needed to establish treatment benefits and durability of gains.

Group cognitive and behavioral treatment for compulsive hoarding: a preliminary trial

BACKGROUND

Time-limited group cognitive behavioral treatments (GCBT) for obsessive-compulsive disorder have demonstrated improvement in target symptoms. One small sample study of GCBT specifically for hoarding problems also showed benefit. This study examines the efficacy of a specialized GCBT for compulsive hoarding on a larger sample.

METHODS

Thirty-two clients diagnosed with hoarding participated in five groups. Four groups met once weekly for 2 hour over 16 weeks (n=27) and one group met for 20 weeks (n=5). All participants had two individual 90-min home sessions. Self-report assessments were completed at baseline, mid-treatment, and post-treatment about hoarding behavior and related symptoms (e.g., depression). The sample was predominantly female, White, highly educated, unemployed, and not partnered/married; mean age was 53. A majority was diagnosed with major depressive disorder and obsessive-compulsive personality disorder.

RESULTS

Participants showed significant improvement from pre- to post-treatment on the Saving Inventory Revised, Saving Cognitions Inventory, Clutter Image Rating, and Clinical Global Severity. The most recent group (n=8) that used a more formalized treatment and research protocol improved significantly more than did earlier members.

CONCLUSION

This study demonstrates the feasibility and modest success of GCBT methods in improving hoarding symptoms. Group treatment may be especially valuable because of its cost-effectiveness, greater client access to trained clinicians, and reduction in social isolation and stigma linked to this problem. Further research is needed to improve the efficacy of GCBT methods for hoarding and to examine durability of change, predictors of outcomes, and processes that influence change.

Relationship of exposure to clinically irrelevant emotion cues and obsessive-compulsive symptoms

Research has highlighted the role of emotion regulation as a common factor underlying emotional disorders. The current study examined the relationship of emotion regulation skills to obsessive-compulsive disorder (OCD) symptoms. Seven participants with a principal diagnosis of OCD in a multiple-baseline across subjects design were taught the skill of prevention of emotional avoidance in the context of emotion provocation procedures to clinically irrelevant (nonspecific) cues prior to practicing this skill with clinically relevant (OCD-specific) cues. Results suggested successful acquisition of emotion regulation skills (as evidenced by decreased thought suppression and increased acceptance of thoughts and feelings) in clinically irrelevant contexts. Acquisition of this skill was associated with decreases in obsessive-compulsive symptoms, even though clinically relevant cues were not introduced during this phase. Implementation of skills in clinically relevant contexts was associated with greater reductions in OCD symptoms. Discussion focuses on implications for emotion regulatory processes in the maintenance and treatment of emotional disorders.

Delivery of internet treatment for compulsive hoarding (D.I.T.C.H.)

This study tested the effectiveness of an existing private online CBT-based group intervention designed to help people with hoarding. Web-group participants were hypothesized to show more improvement in hoarding symptoms over time compared to those placed on a naturalistic waitlist. This web-based self-help group (N = 106 members, N = 155 waitlisted) includes a formal application process and requires that participants post action steps and progress at least once monthly. Members have access to educational resources on hoarding, cognitive strategies, and a chat-group. Potential research participants were invited to complete an anonymous web-based survey about their hoarding behaviors and clinical improvement on five occasions (3 months apart). The sample was mainly middle-aged, female and White. Regression analyses show that Recent members reported greater improvement and less clutter at 6 months (than Waitlist). Long-term members reported milder hoarding symptoms than Recent ones, suggesting benefits from group participation over time. All members showed reductions in clutter and hoarding symptoms over 15 months. Less posting activity was associated with greater hoarding severity. Online CBT-based self-help for hoarding appears to be a promising intervention strategy that may extend access to treatment. Evaluating the benefits of internet self-help groups is critical given growing popularity of and demand for web-based interventions.

The prevalence of compulsive hoarding and its association with compulsive buying in a German population-based sample

The aims of the study were to estimate the prevalence rate of compulsive hoarding, and to determine the association between compulsive hoarding and compulsive buying in a nationally representative sample of the German population (N = 2307). Compulsive hoarding was assessed with the German version of the Saving Inventory-Revised (SI-R; Frost, R.O., Steketee, G., & Grisham, J. (2004). Measurement of compulsive hoarding: saving inventory-revised. Behaviour Research and Therapy, 42, 1163-1182.). The point prevalence of compulsive hoarding was estimated to be 4.6%. Individuals with compulsive hoarding did not differ significantly from those without compulsive hoarding regarding age, gender, and other sociodemographic characteristics. Significant correlations were found between the compulsive hoarding and the compulsive buying measures. Participants with compulsive hoarding reported a higher propensity to compulsive buying than respondents without hoarding. About two thirds of participants classified as having compulsive hoarding were also defined as suffering from compulsive buying. In summary, these results suggest that compulsive hoarding may be relatively prevalent in Germany and they confirm the close association between compulsive hoarding and compulsive buying through the investigation of a large scale representative sample.

The latent structure of obsessive-compulsive symptoms: a taxometric study

There is increasing consensus that obsessive-compulsive (OC) symptoms are heterogeneous clinical phenomena that should be assessed, diagnosed, and treated from a multidimensional perspective. However, it remains unclear whether the heterogeneous OC symptoms represent discrete taxonomic entities. In this study, the categorical versus dimensional nature of OC symptoms and associated cognitions was examined in a large undiagnosed sample using taxometric methods. Six potential OC symptoms (washing, checking, obsessing, neutralizing, ordering, and hoarding) and three potential OC-related cognitions (responsibility/threat estimation, perfectionism/certainty, and importance of thoughts/control of thoughts) were examined using the MAXimum EIGenvalue and mean above minus below a cut procedures. Findings were largely consistent with dimensional models of the latent structure of all OC symptoms and cognitions with the exception of hoarding. The implications of these findings for the clinical assessment and diagnosis of OC symptoms and obsessive-compulsive disorder are discussed.

Interpersonal problems and emotional intelligence in compulsive hoarding

There is some evidence that compulsive hoarding is associated with social impairment, which may contribute to poor functional outcomes among hoarding patients. In this study, individuals with compulsive hoarding (n = 30) were compared to nonhoarding anxious or depressed patients (n = 30) and nonclinical community participants (n = 30) with respect to clinical characteristics, interpersonal difficulties, and emotional intelligence. All participants were diagnosed using a semi-structured interview and completed self-report measures. Participants with compulsive hoarding endorsed more depression and schizotypal personality disorder symptoms than participants in both comparison groups. Hoarding participants also reported more interpersonal difficulties than community volunteers, but they did not differ significantly from nonhoarding participants with an anxiety or mood disorder. Multiple regression analyses demonstrated that hoarding-related beliefs were marginally related to increased interpersonal problems over and above the effect of depression and anxiety. The groups did not differ significantly with respect to emotional intelligence.

Differences in neuropsychological performance between subtypes of obsessive-compulsive disorder

OBJECTIVE

Neuropsychological studies have suggested that frontal-striatal dysfunction plays a role in obsessive-compulsive disorder (OCD), although findings have been inconsistent, possibly due to heterogeneity within the disorder and methodological issues. The purpose of the present study was therefore to compare the neuropsychological performance of different subtypes of OCD and matched non-clinical controls (NCs) on the Cambridge Automated Neuropsychological Test Battery (CANTAB).

METHODS

Fifty-nine OCD patients and 59 non-clinical controls completed selected tests from CANTAB examining executive function, visual memory and attentional-set shifting. Depression, anxiety and OCD symptoms were also assessed.

RESULTS

From 59 OCD patients, four subtypes were identified: (i) washers; (ii) checkers; (iii) obsessionals; and (iv) mixed symptom profile. Comparisons between washers, checkers, obsessionals and NCs indicated few differences, although checkers were generally found to exhibit poorer performance on spatial working memory, while obsessionals performed poorly on the spatial recognition task. Both checkers and the mixed subgroups showed slowed initial movement on the Stockings of Cambridge planning task and poorer pattern recognition relative to NCs.

CONCLUSION

Overall the results suggested greater impairments in performance on neuropsychological tasks in checkers relative to other subtypes, although the observed effects were small and the conclusions limited by the small subtype samples. Future research will need to account for factors that influence neuropsychological performance in OCD subtypes.