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Duholm CS, Jensen S, Rask CU, Thomsen PH, Ivarsson T, Skarphedinsson G, Torp NC, Weidle B, Nissen JB, Højgaard DRMA. Specific Contamination Symptoms are Associated with Experiencing a Limited Response of Cognitive-Behavioral Therapy in Pediatric Patients with OCD. Child Psychiatry Hum Dev 2024; 55:1135-1145. [PMID: 36510026 DOI: 10.1007/s10578-022-01480-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/05/2022] [Indexed: 12/14/2022]
Abstract
A recent study identified three distinct treatment-response trajectories in pediatric OCD where higher levels of contamination symptoms predicted a limited response to cognitive-behavioral therapy (CBT). This study extends these findings by examining which specific symptoms characterize limited CBT response from baseline to 3-year follow-up, with an emphasis on contamination symptoms. The study sample comprised 269 pediatric patients with OCD, all receiving stepped-care treatment with manualized CBT. Differences in single item-reporting between the three trajectory groups were examined using linear mixed-effect modeling. Limited responders displayed a higher symptom load across all OCD symptom categories at 3-year follow-up, dominated by contamination symptoms. Five of these (obsessions about dirt and germs, about bodily fluids, about the feeling of contamination and compulsions regarding handwashing and showering) showed persistence from baseline to 3-year follow-up. The results indicate that presence of specific contamination symptoms may influence long-term symptom severity trajectories in young patients with OCD.
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Affiliation(s)
- Charlotte Steen Duholm
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Psychiatry, Denmark.
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
- Aarhus University Hospital, Psychiatry, Palle Juul-Jensens Boulevard 175, Entrance K, 8200, Aarhus, Denmark.
| | - Sanne Jensen
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Psychiatry, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Charlotte Ulrikka Rask
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Psychiatry, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Per Hove Thomsen
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Psychiatry, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Tord Ivarsson
- Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Nor Christian Torp
- Division of Mental Health and Addiction, Vestre Viken Hospital, Drammen, Norway
- Akershus University Hospital, Oslo, Norway
| | - Bernhard Weidle
- Regional Centre for Child and Youth Mental Health and Child Welfare Central Norway, Norwegian University of Science and Technology, Trondheim, Norway
| | - Judith Becker Nissen
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Psychiatry, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Davíð R M A Højgaard
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Psychiatry, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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de Jong R, Lommen MJJ, de Jong PJ, van Hout WJPJ, Duin-van der Marel ACE, Nauta MH. Effectiveness of exposure-based treatment for childhood anxiety disorders: An open clinical trial to test its relation with indices of emotional processing and inhibitory learning. J Behav Ther Exp Psychiatry 2024; 83:101942. [PMID: 38309121 DOI: 10.1016/j.jbtep.2024.101942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 12/22/2023] [Accepted: 01/08/2024] [Indexed: 02/05/2024]
Abstract
BACKGROUND AND OBJECTIVES The current study examined how effectiveness of exposure-based CBT was related to indices of emotional processing and inhibitory learning during exposure exercises. METHODS Adolescents with anxiety disorder(s) (N = 72; age 11-19; 85% girls) received a group-based, intensive two-week treatment of which effectiveness was indexed by the SCARED and by ratings of anxiety and approach towards individualized goal situations. To index emotional processing, subjective units of distress (SUDs) were used to indicate both initial and final fear level, and absolute, relative, and total dose of fear reduction. To index inhibitory learning, subjective threat expectancies (STEs) were used to indicate initial and final threat expectancy, and absolute, relative, and total dose of expectancy change. RESULTS From pre-treatment to follow-up, there was a large-sized reduction of anxiety symptoms, small-sized decrease of subjective anxiety and a large-sized increase in subjective approach towards individual treatment goals. Higher fear levels prior to exposure were related to a larger decrease of symptoms. Higher threat expectancies after exposure exercises were independently associated with less decrease of anxiety and increase of approach towards treatment goals. Total dose of experienced fear reduction and total dose of experienced expectancy change were (partly) independently related to more increase in approach towards individualized goal situations. LIMITATIONS As patients also received other treatment elements, the results cannot be interpreted unequivocally. CONCLUSIONS The pattern of findings seems to indicate that emotional processing (as indexed by fear reduction) and inhibitory learning (as indexed by expectancy change) are both relevant in exposure-based CBT.
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Affiliation(s)
- Rachel de Jong
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands.
| | - Miriam J J Lommen
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands
| | - Peter J de Jong
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands
| | - Wiljo J P J van Hout
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands
| | | | - Maaike H Nauta
- University of Groningen, Department of Clinical Psychology and Experimental Psychopathology, the Netherlands
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Seidel DH, Markes M, Grouven U, Messow CM, Sieben W, Knelangen M, Oelkers-Ax R, Grümer S, Kölsch H, Kromp M, von Pluto Prondzinski M. Systemic therapy in children and adolescents with mental disorders: a systematic review and meta-analysis. BMC Psychiatry 2024; 24:125. [PMID: 38355466 PMCID: PMC10868021 DOI: 10.1186/s12888-024-05556-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 01/23/2024] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Systemic therapy (ST) is a psychotherapeutic intervention in complex human systems (both psychological and interpersonal). Cognitive behavioural therapy (CBT) is an established treatment for children and adolescents with mental disorders. As methodologically rigorous systematic reviews on ST in this population are lacking, we conducted a systematic review and meta-analysis to compare the benefit and harm of ST (and ST as an add-on to CBT) with CBT in children and adolescents with mental disorders. METHODS We searched MEDLINE, Embase, PsycINFO and other sources for randomised controlled trials in 14 mental disorder classes for the above comparisons in respect of effects on patient-relevant outcomes (search date: 7/2022). Where possible, meta-analyses were performed and results were graded into 3 different evidence categories: "proof", "indication", or "hint" (or none of these categories). PRISMA standards were followed. RESULTS Fifteen studies in 5 mental disorder classes with usable data were identified. 2079 patients (mean age: 10 to 19 years) were analysed. 12/15 studies and 29/30 outcomes showed a high risk of bias. In 2 classes, statistically significant and clinically relevant effects in favour of ST were found, supporting the conclusion of a hint of greater benefit of ST for mental and behavioural disorders due to psychoactive substance use and of ST as an add-on to CBT for obsessive-compulsive disorders. In 2 other classes (eating disorders; hyperkinetic disorders), there was no evidence of greater benefit or harm of ST. For affective disorders, a statistically significant effect to the disadvantage of ST was found for 1 outcome, supporting the conclusion of a hint of lesser benefit of ST. CONCLUSIONS Our results show a hint of greater benefit of ST (or ST as an add-on to CBT) compared with CBT for 2 mental disorder classes in children and adolescents (mental and behavioural disorders due to psychoactive substance use, obsessive compulsive disorders). Given the importance of CBT as a control intervention, ST can therefore be considered a beneficial treatment option for children and adolescents with certain mental disorders. Limitations include an overall high risk of bias of studies and outcomes and a lack of data for several disorders.
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Affiliation(s)
- David Henry Seidel
- Institute for Quality and Efficiency in Health Care (Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen, IQWiG), Im Mediapark 8, Cologne, 50670, Germany.
| | - Martina Markes
- Institute for Quality and Efficiency in Health Care (Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen, IQWiG), Im Mediapark 8, Cologne, 50670, Germany
| | - Ulrich Grouven
- Institute for Quality and Efficiency in Health Care (Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen, IQWiG), Im Mediapark 8, Cologne, 50670, Germany
| | - Claudia-Martina Messow
- Institute for Quality and Efficiency in Health Care (Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen, IQWiG), Im Mediapark 8, Cologne, 50670, Germany
| | - Wiebke Sieben
- Institute for Quality and Efficiency in Health Care (Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen, IQWiG), Im Mediapark 8, Cologne, 50670, Germany
| | - Marco Knelangen
- Institute for Quality and Efficiency in Health Care (Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen, IQWiG), Im Mediapark 8, Cologne, 50670, Germany
| | - Rieke Oelkers-Ax
- Family Therapy Centre (Familientherapeutisches Zentrum gGmbH, FaTZ), Hermann-Walker-Straße 16, 69151, Neckargemünd, Germany
| | - Sebastian Grümer
- Institute for Quality and Efficiency in Health Care (Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen, IQWiG), Im Mediapark 8, Cologne, 50670, Germany
| | - Heike Kölsch
- Institute for Quality and Efficiency in Health Care (Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen, IQWiG), Im Mediapark 8, Cologne, 50670, Germany
| | - Mandy Kromp
- Institute for Quality and Efficiency in Health Care (Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen, IQWiG), Im Mediapark 8, Cologne, 50670, Germany
| | - Markus von Pluto Prondzinski
- Institute for Quality and Efficiency in Health Care (Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen, IQWiG), Im Mediapark 8, Cologne, 50670, Germany
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Pretzmann L, Christensen SH, Bryde Christensen A, Funch Uhre C, Uhre V, Thoustrup CL, Clemmesen IT, Gudmandsen TA, Korsbjerg NLJ, Mora-Jensen ARC, Ritter M, Olsen MH, Clemmensen LKH, Lindschou J, Gluud C, Thomsen PH, Vangkilde S, Hagstrøm J, Rozental A, Jeppesen P, Verhulst F, Hybel KA, Lønfeldt NN, Plessen KJ, Poulsen S, Pagsberg AK. Adverse events in cognitive behavioral therapy and relaxation training for children and adolescents with obsessive-compulsive disorder: A mixed methods study and analysis plan for the TECTO trial. Contemp Clin Trials Commun 2023; 34:101173. [PMID: 37497354 PMCID: PMC10366479 DOI: 10.1016/j.conctc.2023.101173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 05/29/2023] [Accepted: 06/19/2023] [Indexed: 07/28/2023] Open
Abstract
Background Knowledge on adverse events in psychotherapy for youth with OCD is sparse. No official guidelines exist for defining or monitoring adverse events in psychotherapy. Recent recommendations call for more qualitative and quantitative assessment of adverse events in psychotherapy trials. This mixed methods study aims to expand knowledge on adverse events in psychotherapy for youth with OCD. Methods This is an analysis plan for a convergent mixed methods study within a randomized clinical trial (the TECTO trial). We include at least 128 youth aged 8-17 years with obsessive-compulsive disorder (OCD). Participants are randomized to either family-based cognitive behavioral therapy (FCBT) or family-based psychoeducation and relaxation training (FPRT). Adverse events are monitored quantitatively with the Negative Effects Questionnaire. Furthermore, we assess psychiatric symptoms, global functioning, quality of life, and family factors to investigate predictors for adverse events. We conduct semi-structured qualitative interviews with all youths and their parents on their experience of adverse events in FCBT or FPRT. For the mixed methods analysis, we will merge 1) a qualitative content analysis with descriptive statistics comparing the types, frequencies, and severity of adverse events; 2) a qualitative content analysis of the perceived causes for adverse events with prediction models for adverse events; and 3) a thematic analysis of the participants' treatment evaluation with a correlational analysis of adverse events and OCD severity. Discussion The in-depth mixed methods analysis can inform 1) safer and more effective psychotherapy for OCD; 2) instruments and guidelines for monitoring adverse events; and 3) patient information on potential adverse events. The main limitation is risk of missing data. Trial registration ClinicalTrials.gov identifier: NCT03595098. Registered on July 23, 2018.
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Affiliation(s)
- Linea Pretzmann
- Child and Adolescent Mental Health Center, Copenhagen University Hospital, Mental Health Services, CPH, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Sofie Heidenheim Christensen
- Child and Adolescent Mental Health Center, Copenhagen University Hospital, Mental Health Services, CPH, Copenhagen, Denmark
| | - Anne Bryde Christensen
- Center for Eating and feeding Disorders Research, Mental Health Center Ballerup, Capital Region of Denmark
| | - Camilla Funch Uhre
- Child and Adolescent Mental Health Center, Copenhagen University Hospital, Mental Health Services, CPH, Copenhagen, Denmark
- Center for Clinical Neuropsychology, Children and Adolescents, Rigshospitalet, Copenhagen, Denmark
| | - Valdemar Uhre
- Child and Adolescent Mental Health Center, Copenhagen University Hospital, Mental Health Services, CPH, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Danish Research Centre for Magnetic Resonance, Centre for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital ─ Amager and Hvidovre, Copenhagen, Denmark
| | - Christine Lykke Thoustrup
- Child and Adolescent Mental Health Center, Copenhagen University Hospital, Mental Health Services, CPH, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Iben Thiemer Clemmesen
- Child and Adolescent Mental Health Center, Copenhagen University Hospital, Mental Health Services, CPH, Copenhagen, Denmark
| | - Tin Aaen Gudmandsen
- Child and Adolescent Mental Health Center, Copenhagen University Hospital, Mental Health Services, CPH, Copenhagen, Denmark
| | | | - Anna-Rosa Cecilie Mora-Jensen
- Child and Adolescent Mental Health Center, Copenhagen University Hospital, Mental Health Services, CPH, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Melanie Ritter
- Child and Adolescent Mental Health Center, Copenhagen University Hospital, Mental Health Services, CPH, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Markus Harboe Olsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital ─ Rigshospitalet, Copenhagen, Denmark
- Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital ─ Rigshospitalet, Copenhagen, Denmark
| | | | - Jane Lindschou
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital ─ Rigshospitalet, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital ─ Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Per Hove Thomsen
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Psychiatry, Aarhus, Denmark
| | - Signe Vangkilde
- Child and Adolescent Mental Health Center, Copenhagen University Hospital, Mental Health Services, CPH, Copenhagen, Denmark
- Department of Psychology, Faculty of Social Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Julie Hagstrøm
- Child and Adolescent Mental Health Center, Copenhagen University Hospital, Mental Health Services, CPH, Copenhagen, Denmark
| | - Alexander Rozental
- Department of Clinical Neuroscience (CNS), Centre for Psychiatry Research, Karolinska Institute, Sweden
| | - Pia Jeppesen
- Child and Adolescent Mental Health Center, Copenhagen University Hospital, Mental Health Services, CPH, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Child and Adolescent Psychiatry, Copenhagen University Hospital – Psychiatry Region Zealand, Roskilde, Denmark
| | - Frank Verhulst
- Child and Adolescent Mental Health Center, Copenhagen University Hospital, Mental Health Services, CPH, Copenhagen, Denmark
| | - Katja Anna Hybel
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Psychiatry, Aarhus, Denmark
| | - Nicole Nadine Lønfeldt
- Child and Adolescent Mental Health Center, Copenhagen University Hospital, Mental Health Services, CPH, Copenhagen, Denmark
| | - Kerstin Jessica Plessen
- Child and Adolescent Mental Health Center, Copenhagen University Hospital, Mental Health Services, CPH, Copenhagen, Denmark
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Stig Poulsen
- Department of Psychology, Faculty of Social Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Anne Katrine Pagsberg
- Child and Adolescent Mental Health Center, Copenhagen University Hospital, Mental Health Services, CPH, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Mendez EM, Dahlsgaard KK, Hjelmgren JM, Mills JA, Suresh V, Strawn JR. What Is the Added Benefit of Combining Cognitive Behavioral Therapy and Selective Serotonin Reuptake Inhibitors in Youth with Obsessive Compulsive Disorder? A Bayesian Hierarchical Modeling Meta-Analysis. J Child Adolesc Psychopharmacol 2023; 33:203-211. [PMID: 37347947 PMCID: PMC10458367 DOI: 10.1089/cap.2023.0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
Background: Treatment of obsessive-compulsive disorder (OCD) in children and adolescents frequently involves cognitive behavioral therapy (CBT), selective serotonin reuptake inhibitors (SSRIs), or their combination. However, how adding CBT to SSRIs affects the trajectory and magnitude of improvement has not been evaluated meta-analytically. Methods: We performed a meta-analysis using weekly data from prospective randomized parallel group trials of CBT and SSRIs in pediatric patients with OCD. Response was modeled for the change in the Child Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) using a Bayesian hierarchical model over 12 weeks. Results: Fourteen studies included pharmacotherapy arms, 4 studies included combined pharmacotherapy and psychotherapy, and 10 studies included a placebo or control arm. The studies included 1146 patients (mean age 12.7 ± 1.3 years, mean 42.1% female). In the logarithmic model of response, statistically significant differences in treatment effects for CBT+SSRI and SSRI monotherapy were observed compared with placebo (SSRI β = -3.59, credible interval [95% CrI]: -4.13 to -3.02, p < 0.001; SSRI+CBT β = -4.07, 95% CrI: -5.05 to -3.04, p < 0.001). Adding CBT to an SSRI produced numerically (but not statistically significantly) greater improvement over 12 weeks. Greater improvement was observed in studies with more boys (p < 0.001), younger patients (p < 0.001), and in studies with greater baseline symptom severity (p < 0.001). Conclusions: In children and adolescents with OCD, compared with placebo, both SSRIs and SSRI+CBT produced early and sustained improvement over 12 weeks, although the improvement was also related to sample characteristics. Longer term studies are needed to determine when the additive benefit of CBT emerges relative to SSRI monotherapy.
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Affiliation(s)
- Eric M. Mendez
- Department of Psychiatry & Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | | | - John M. Hjelmgren
- Department of Psychiatry & Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Jeffrey A. Mills
- Department of Economics, Lindner College of Business, University of Cincinnati, Cincinnati, Ohio, USA
| | - Vikram Suresh
- Department of Economics, Lindner College of Business, University of Cincinnati, Cincinnati, Ohio, USA
| | - Jeffrey R. Strawn
- Department of Psychiatry & Behavioral Neuroscience, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Divisions of Child & Adolescent Psychiatry and Clinical Pharmacology, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Lønfeldt NN, Clemmensen LKH, Pagsberg AK. A Wearable Artificial Intelligence Feedback Tool (Wrist Angel) for Treatment and Research of Obsessive Compulsive Disorder: Protocol for a Nonrandomized Pilot Study. JMIR Res Protoc 2023; 12:e45123. [PMID: 37486738 PMCID: PMC10407771 DOI: 10.2196/45123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 03/30/2023] [Accepted: 04/30/2023] [Indexed: 07/25/2023] Open
Abstract
BACKGROUND Obsessive compulsive disorder (OCD) in youth is characterized by behaviors, emotions, physiological reactions, and family interaction patterns. An essential component of therapy involves increasing awareness of the links among thoughts, emotions, behaviors, bodily sensations, and family interactions. An automatic assessment tool using physiological signals from a wearable biosensor may enable continuous symptom monitoring inside and outside of the clinic and support cognitive behavioral therapy for OCD. OBJECTIVE The primary aim of this study is to evaluate the feasibility and acceptability of using a wearable biosensor to monitor OCD symptoms. The secondary aim is to explore the feasibility of developing clinical and research tools that can detect and predict OCD-relevant internal states and interpersonal processes with the use of speech and behavioral signals. METHODS Eligibility criteria for the study include children and adolescents between 8 and 17 years of age diagnosed with OCD, controls with no psychiatric diagnoses, and one parent of the participating youths. Youths and parents wear biosensors on their wrists that measure pulse, electrodermal activity, skin temperature, and acceleration. Patients and their parents mark OCD episodes, while control youths and their parents mark youth fear episodes. Continuous, in-the-wild data collection will last for 8 weeks. Controlled experiments designed to link physiological, speech, behavioral, and biochemical signals to mental states are performed at baseline and after 8 weeks. Interpersonal interactions in the experiments are filmed and coded for behavior. The films are also processed with computer vision and for speech signals. Participants complete clinical interviews and questionnaires at baseline, and at weeks 4, 7, and 8. Feasibility criteria were set for recruitment, retention, biosensor functionality and acceptability, adherence to wearing the biosensor, and safety related to the biosensor. As a first step in learning the associations between signals and OCD-related parameters, we will use paired t tests and mixed effects models with repeated measures to assess associations between oxytocin, individual biosignal features, and outcomes such as stress-rest and case-control comparisons. RESULTS The first participant was enrolled on December 3, 2021, and recruitment closed on December 31, 2022. Nine patient dyads and nine control dyads were recruited. Sixteen participating dyads completed follow-up assessments. CONCLUSIONS The results of this study will provide preliminary evidence for the extent to which a wearable biosensor that collects physiological signals can be used to monitor OCD severity and events in youths. If we find the study to be feasible, further studies will be conducted to integrate biosensor signals output into machine learning algorithms that can provide patients, parents, and therapists with actionable insights into OCD symptoms and treatment progress. Future definitive studies will be tasked with testing the accuracy of machine learning models to detect and predict OCD episodes and classify clinical severity. TRIAL REGISTRATION ClinicalTrials.gov NCT05064527; https://clinicaltrials.gov/ct2/show/NCT05064527. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/45123.
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Affiliation(s)
- Nicole Nadine Lønfeldt
- Child and Adolescent Mental Health Center, Mental Health Services CPH, Copenhagen University Hospital, Hellerup, Denmark
| | | | - Anne Katrine Pagsberg
- Child and Adolescent Mental Health Center, Mental Health Services CPH, Copenhagen University Hospital, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Bilek EL, Meyer AE, Tomlinson R, Chen C. Pilot Study of Self-Distancing Augmentation to Exposure Therapy for Youth Anxiety. Child Psychiatry Hum Dev 2023:10.1007/s10578-023-01540-x. [PMID: 37231323 DOI: 10.1007/s10578-023-01540-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/30/2023] [Indexed: 05/27/2023]
Abstract
This pilot examines a self-distancing augmentation to exposure. Nine youth with anxiety (ages 11-17; 67% female) completed treatment. The study employed a brief (eight session) crossover ABA/BAB design. Exposure difficulty, engagement with exposure, and treatment acceptability were examined as primary outcome variables. Visual inspection of plots indicated that youth completed more difficult exposures during augmented exposure sessions [EXSD] than classic exposure sessions [EX] by therapist- and youth-report and that therapists reported higher youth engagement during EXSD than EX sessions. There were no significant differences between EXSD and EX on exposure difficulty or engagement by therapist- or youth-report. Treatment acceptability was high, although some youth reported that self-distancing was "awkward". Self-distancing may be associated with increased exposure engagement and willingness to complete more difficult exposures, which has been linked to treatment outcomes. Future research is needed to further demonstrate this link, and link self-distancing to outcomes directly.
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Affiliation(s)
- Emily L Bilek
- Department of Psychiatry, Michigan Medicine, University of Michigan, 4250 Plymouth Rd., SPC 5765, Ann Arbor, MI, 48109, USA.
| | - Allison E Meyer
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Rachel Tomlinson
- Department of Psychology, University of Michigan, Ann Arbor, MI, USA
| | - Carol Chen
- Department of Psychiatry, Michigan Medicine, University of Michigan, 4250 Plymouth Rd., SPC 5765, Ann Arbor, MI, 48109, USA
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Guastello AD, Lieneman C, Bailey B, Munson M, Barthle-Herrera M, Higham M, Druskin L, McNeil CB. Case report: Co-occurring autism spectrum disorder (Level One) and obsessive-compulsive disorder in a gender-diverse adolescent. Front Psychiatry 2023; 14:1072645. [PMID: 37260756 PMCID: PMC10227521 DOI: 10.3389/fpsyt.2023.1072645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 03/06/2023] [Indexed: 06/02/2023] Open
Abstract
This fictionalized case report captures the common themes and considerations during the diagnostic assessment and behavioral treatment of adolescents demonstrating symptoms of autism spectrum disorder (ASD), obsessive-compulsive disorder (OCD), and attention-deficit/hyperactivity disorder (ADHD), as well as gender-diversity concerns. Our patient was a white, non-Hispanic 17-year-old individual who identified as gender-neutral but had been assigned female at birth. Symptoms presented were social withdrawal, rigid rule-following behavior, unusual repetitive behavior, impairments in social communication skills, sensory sensitivity, body dissatisfaction, self-injury, and anxiety related to contamination, perfectionism, and social interactions. These symptoms contributed to functional impairment with school attendance, school achievement, family relationships, and the activities of daily living. This case report summarizes instruments employed for differential diagnosis concerning cognitive functioning, ASD, OCD, ADHD, depression, anxiety, and commonly co-occurring repetitive behavior. This patient was ultimately diagnosed with ASD, level one for both social communication and restricted, repetitive behaviors, without accompanying intellectual or language impairment; OCD with panic attacks; gender dysphoria; major depressive disorder (single episode and moderate); and ADHD. The subsequent 40-session course of cognitive-behavioral therapy with exposure and response prevention (CBT/ERP) to treat OCD tailored to an individual with ASD and gender diversity concerns is described in detail. Components of family involvement are highlighted. As a result, significant improvements in school attendance, OCD symptoms, depression, social relationships, and adaptive functioning were measured. Lastly, recommendations for clinicians are summarized.
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Affiliation(s)
- Andrea D. Guastello
- Florida Exposure and Anxiety Research (FEAR) Laboratory, Department of Psychiatry, University of Florida, Gainesville, FL, United States
| | - Corey Lieneman
- Department of Psychiatry, University of Nebraska Medical Center, Omaha, NE, United States
| | - Brittany Bailey
- Florida Exposure and Anxiety Research (FEAR) Laboratory, Department of Psychiatry, University of Florida, Gainesville, FL, United States
| | - Melissa Munson
- Florida Exposure and Anxiety Research (FEAR) Laboratory, Department of Psychiatry, University of Florida, Gainesville, FL, United States
| | - Megan Barthle-Herrera
- Florida Exposure and Anxiety Research (FEAR) Laboratory, Department of Psychiatry, University of Florida, Gainesville, FL, United States
| | - Miranda Higham
- Department of School Psychology, University of Florida, Gainesville, FL, United States
| | - Lindsay Druskin
- Department of Psychology, West Virginia University, Morgantown, WV, United States
| | - Cheryl B. McNeil
- Florida Exposure and Anxiety Research (FEAR) Laboratory, Department of Psychiatry, University of Florida, Gainesville, FL, United States
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9
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Winkler CD, Koval P, Phillips LJ, Felmingham KL. Does prediction error during exposure relate to clinical outcomes in cognitive behavior therapy for social anxiety disorder? A study protocol. Front Psychiatry 2022; 13:1000686. [PMID: 37082515 PMCID: PMC10111196 DOI: 10.3389/fpsyt.2022.1000686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 11/08/2022] [Indexed: 11/25/2022] Open
Abstract
Facing your fears, or exposure therapy, is an effective psychological intervention for anxiety disorders that is often thought to work through fear extinction learning. Fear extinction learning is a type of associative learning where fear reduces through repeated encounters with a feared situation or stimulus in the absence of aversive outcomes. Laboratory research suggests fear extinction learning is driven by threat prediction errors, defined as when fearful predictions do not eventuate. Threat prediction error and its relationship to exposure therapy outcomes haven't been studied enough in actual therapy settings. It remains unclear whether prediction error and extinction learning are central mechanisms of exposure therapy. We are conducting a longitudinal and observational study of how threat prediction error during exposure in social anxiety disorder (SAD) treatment relates to session-by-session symptom change and treatment outcome in addition to exposure surprise and learning outcome. We aim to recruit 65 adults with a primary diagnosis of SAD through an outpatient psychology clinic. Participants will receive 12 sessions of individual manualized cognitive behavioral therapy (CBT), adapted from an efficacious group protocol, that includes graded exposure. Exposure processes, including self-report measures of anxiety, threat prediction, threat outcomes, surprise, and learning outcome, will be measured with smartphone-based event-contingent ecological momentary assessments (EMAs) of all behavioral experiments completed during treatment. Clinical outcomes include self-reported social anxiety symptoms and social threat appraisals, at each session, post and 3-months after treatment. Prediction error will be operationalized as the mismatch between the threat prediction and threat outcome. The joint effect of threat prediction and threat outcome on session-by-session symptom change, treatment outcome, exposure surprise, and learning outcome will be explored using multilevel modeling. The present study will help determine whether threat prediction error during exposures in SAD treatment is related to theoretically implied clinical outcomes. This would contribute to the larger research aim of clarifying exposure therapy mechanisms.
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Affiliation(s)
- Christopher D. Winkler
- Melbourne School of Psychological Sciences, University of Melbourne, Melbourne, VIC, Australia
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10
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Elsner B, Jacobi T, Kischkel E, Schulze D, Reuter B. Mechanisms of exposure and response prevention in obsessive-compulsive disorder: effects of habituation and expectancy violation on short-term outcome in cognitive behavioral therapy. BMC Psychiatry 2022; 22:66. [PMID: 35086513 PMCID: PMC8793233 DOI: 10.1186/s12888-022-03701-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 12/23/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Exposure and response prevention is effective and recommended as the first choice for treating obsessive-compulsive disorders (OCD). Its mechanisms of action are rarely studied, but two major theories make distinct assumptions: while the emotional processing theory assumes that treatment effects are associated with habituation within and between exposure sessions, the inhibitory learning approach highlights the acquisition of additional associations, implying alternative mechanisms like expectancy violation. The present study aimed to investigate whether process variables derived from both theories predict short-term outcome. METHOD In a university outpatient unit, 110 patients (63 female) with OCD received manual-based cognitive-behavioral therapy with high standardization of the first two exposure sessions. Specifically, therapists repeated the first exposure session identically and assessed subjective units of distress as well as expectancy ratings in the course of exposure sessions. Based on these data, individual scores for habituation and distress-related expectancy violation were calculated and used for prediction of both percentage change on the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and remission status after 20 therapy sessions. RESULTS In a multiple regression model for percentage change, within-session habituation during the first exposure was a significant predictor, while in a logistic regression predicting remission status, distress-related expectancy violation during the first exposure revealed significance. A path model further supported these findings. CONCLUSIONS The results represent first evidence for distress-related expectancy violation and confirm preliminary findings for habituation, suggesting that both processes contribute to treatment benefits of exposure in OCD, and both mechanisms appear to be independent.
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Affiliation(s)
- Björn Elsner
- Department of Psychology, Humboldt-Universität zu Berlin, Rudower Chaussee 18, 12489 Berlin, Germany
| | - Tanja Jacobi
- Department of Psychology, Humboldt-Universität zu Berlin, Rudower Chaussee 18, 12489 Berlin, Germany
| | - Eva Kischkel
- Department of Psychology, Humboldt-Universität zu Berlin, Rudower Chaussee 18, 12489 Berlin, Germany
| | - Daniel Schulze
- Department of Psychology, Humboldt-Universität zu Berlin, Rudower Chaussee 18, 12489 Berlin, Germany
- Department of Psychology, Freie Universität Berlin, Habelschwerdter Allee 45, 14195 Berlin, Germany
| | - Benedikt Reuter
- Department of Psychology, Humboldt-Universität zu Berlin, Rudower Chaussee 18, 12489 Berlin, Germany
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11
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Van Noppen B, Sassano-Higgins S, Appasani R, Sapp F. Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder: 2021 Update. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2021; 19:430-443. [PMID: 35747293 PMCID: PMC9063577 DOI: 10.1176/appi.focus.20210015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
In this update of a previous review, the authors discuss cognitive-behavioral therapy (CBT) with exposure and response prevention for obsessive-compulsive disorder (OCD). This efficacious modality avoids side effects common to psychotropic medication and reduces risk of relapse once treatment has ended. Psychotherapy involves identification and ranking of stimuli that provoke obsessions, exposure to these stimuli while preventing compulsions, and cognitive restructuring. The family of the OCD patient plays a significant role in treatment. This article includes expanded research on family-focused CBT and treatment of pediatric OCD. The family's accommodation and emotional response to a patient's symptoms may interfere with therapy and perpetuate the disorder. The treatment of pediatric OCD involves the same considerations. However, the form of obsessions and compulsions may differ and therapeutic techniques are modified to make them age appropriate.
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Affiliation(s)
- Barbara Van Noppen
- Department of Psychiatry and Behavioral Sciences, Keck School of Medicine, University of Southern California, Los Angeles (Van Noppen); private practice, Los Angeles (Sassano-Higgins, Appasani); OCD and Anxiety Psychological Services, Calgary, Alberta, Canada (Sapp)
| | - Sean Sassano-Higgins
- Department of Psychiatry and Behavioral Sciences, Keck School of Medicine, University of Southern California, Los Angeles (Van Noppen); private practice, Los Angeles (Sassano-Higgins, Appasani); OCD and Anxiety Psychological Services, Calgary, Alberta, Canada (Sapp)
| | - Raghu Appasani
- Department of Psychiatry and Behavioral Sciences, Keck School of Medicine, University of Southern California, Los Angeles (Van Noppen); private practice, Los Angeles (Sassano-Higgins, Appasani); OCD and Anxiety Psychological Services, Calgary, Alberta, Canada (Sapp)
| | - Felicity Sapp
- Department of Psychiatry and Behavioral Sciences, Keck School of Medicine, University of Southern California, Los Angeles (Van Noppen); private practice, Los Angeles (Sassano-Higgins, Appasani); OCD and Anxiety Psychological Services, Calgary, Alberta, Canada (Sapp)
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12
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Hollmann K, Allgaier K, Hohnecker CS, Lautenbacher H, Bizu V, Nickola M, Wewetzer G, Wewetzer C, Ivarsson T, Skokauskas N, Wolters LH, Skarphedinsson G, Weidle B, de Haan E, Torp NC, Compton SN, Calvo R, Lera-Miguel S, Haigis A, Renner TJ, Conzelmann A. Internet-based cognitive behavioral therapy in children and adolescents with obsessive compulsive disorder: a feasibility study. J Neural Transm (Vienna) 2021; 128:1445-1459. [PMID: 34432173 PMCID: PMC8386338 DOI: 10.1007/s00702-021-02409-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/13/2021] [Indexed: 12/17/2022]
Abstract
Cognitive behavioral therapy (CBT) is the first choice of treatment of obsessive–compulsive disorder (OCD) in children and adolescents. However, there is often a lack of access to appropriate treatment close to the home of the patients. An internet-based CBT via videoconferencing could facilitate access to state-of-the-art treatment even in remote areas. The aim of this study was to investigate feasibility and acceptability of this telemedical approach. A total of nine children received 14 sessions of CBT. The first session took place face-to-face, the remaining 13 sessions via videoconference. OCD symptoms were recorded with a smartphone app and therapy materials were made accessible in a data cloud. We assessed diagnostic data before and after treatment and obtained measures to feasibility, treatment satisfaction and acceptability. Outcomes showed high acceptance and satisfaction on the part of patients with online treatment (89%) and that face-to-face therapy was not preferred over an internet-based approach (67%). The majority of patients and their parents classified the quality of treatment as high. They emphasized the usefulness of exposures with response prevention (E/RP) in triggering situations at home. The app itself was rated as easy to operate and useful. In addition to feasibility, a significant decrease in obsessive–compulsive symptoms was also achieved. Internet-based CBT for pediatric OCD is feasible and well received by the patients and their parents. Furthermore, obsessive–compulsive symptomatology decreased in all patients. The results of this study are encouraging and suggest the significance of further research regarding this technology-supported approach, with a specific focus on efficacy. Trial registration number: Clinical trials AZ53-5400.1-004/44.
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Affiliation(s)
- Karsten Hollmann
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Tübingen, Osianderstr. 5, 72076, Tübingen, Germany
| | - Katharina Allgaier
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Tübingen, Osianderstr. 5, 72076, Tübingen, Germany
| | - Carolin S Hohnecker
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Tübingen, Osianderstr. 5, 72076, Tübingen, Germany
| | | | - Verena Bizu
- Section for Information Technology, University Hospital Tübingen, Tübingen, Germany
| | | | - Gunilla Wewetzer
- Child and Adolescent Psychiatry and Psychotherapy, Clinics of the City of Cologne, Cologne, Germany
| | - Christoph Wewetzer
- Child and Adolescent Psychiatry and Psychotherapy, Clinics of the City of Cologne, Cologne, Germany
| | - Tord Ivarsson
- Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
| | - Norbert Skokauskas
- Regional Centre for Child and Youth Mental Health and Child Welfare Faculty of Medicine and Health Sciences, Trondheim, Norway
| | - Lidewij H Wolters
- Regional Centre for Child and Youth Mental Health and Child Welfare Faculty of Medicine and Health Sciences, Trondheim, Norway
| | | | - Bernhard Weidle
- Regional Centre for Child and Youth Mental Health and Child Welfare, Trondheim, Norway
| | - Else de Haan
- Academic Center for Child and Adolescent Psychiatry, Amsterdam, The Netherlands
| | - Nor Christan Torp
- Centre for Child and Adolescent Mental Health, Eastern and Southern, Division of Mental Health and Addiction, Oslo, Norway.,Division of Mental Health Services, Akershus University Hospital, Lørenskog, Norway
| | | | - Rosa Calvo
- Department of Child and Adolescent Psychiatry and Psychology, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Sara Lera-Miguel
- Department of Child and Adolescent Psychiatry and Psychology, Hospital Clinic of Barcelona, Barcelona, Spain.,CIBERSAM, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Anna Haigis
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Tübingen, Osianderstr. 5, 72076, Tübingen, Germany
| | - Tobias J Renner
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Tübingen, Osianderstr. 5, 72076, Tübingen, Germany
| | - Annette Conzelmann
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Tübingen, Osianderstr. 5, 72076, Tübingen, Germany. .,Department of Psychology (Clinical Psychology II), PFH-Private University of Applied Sciences, Göttingen, Germany.
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13
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Benito KG, Herren J, Freeman JB, Garcia AM, Block P, Cantor E, Chorpita BF, Wellen B, Stewart E, Georgiadis C, Frank H, Machan J. Improving Delivery Behaviors During Exposure for Pediatric OCD: A Multiple Baseline Training Trial With Community Therapists. Behav Ther 2021; 52:806-820. [PMID: 34134822 PMCID: PMC8217728 DOI: 10.1016/j.beth.2020.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 08/28/2020] [Accepted: 10/14/2020] [Indexed: 12/19/2022]
Abstract
This study tested whether a new training tool, the Exposure Guide (EG), improved in-session therapist behaviors (i.e., indicators of quality) that have been associated with youth outcomes in prior clinical trials of exposure therapy. Six therapists at a community mental health agency (CMHA) provided exposure therapy for 8 youth with obsessive-compulsive disorder (OCD). Using a nonconcurrent multiple baseline design with random assignment to baseline lengths of 6 to 16 weeks, therapists received gold-standard exposure therapy training with weekly consultation (baseline phase) followed by addition of EG training and feedback (intervention phase). The primary outcome was therapist behavior during in-session exposures, observed weekly using a validated coding system. Therapist behavior was evaluated in relation to a priori benchmarks derived from clinical trials. Additional outcomes included training feasibility/acceptability, therapist response to case vignettes and beliefs about exposure, and independent evaluator-rated clinical outcomes. Three therapists reached behavior benchmarks only during the EG (intervention) phase. Two therapists met benchmarks during the baseline phase; one of these subsequently moved away from benchmarks but met them again after starting the EG phase. Across all therapists, the percentage of weeks meeting benchmarks was significantly higher during the EG phase (86.4%) vs. the baseline phase (53.2%). Youth participants experienced significant improvement in OCD symptoms and global illness severity from pre- to posttreatment. Results provide initial evidence that adding the EG to gold-standard training can change in-session therapist behaviors in a CMHA setting.
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Affiliation(s)
| | | | | | | | - Paul Block
- William James College; Cadence Consultants
| | | | | | | | | | | | - Hannah Frank
- Warren Alpert Medical School of Brown University; Temple University
| | - Jason Machan
- Lifespan Biostatistics Core, Lifespan Hospitals; Warren Alpert Medical School of Brown University; University of Rhode Island
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14
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Plaisted H, Waite P, Gordon K, Creswell C. Optimising Exposure for Children and Adolescents with Anxiety, OCD and PTSD: A Systematic Review. Clin Child Fam Psychol Rev 2021; 24:348-369. [PMID: 33547624 PMCID: PMC8131290 DOI: 10.1007/s10567-020-00335-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2020] [Indexed: 11/02/2022]
Abstract
Cognitive behavioural therapy is an effective treatment for anxiety disorders in children and young people; however, many do not benefit. Behavioural exposure appears to be the critical ingredient in the treatment of anxiety disorders. Research with adults has identified innovative strategies to optimise exposure-based treatments, yet it is not clear how to optimise the effects of exposure for children and young people. This review was a preliminary exploration of the association between potential optimisation strategies and treatment procedures and outcomes for the treatment of child anxiety symptoms/disorders. We searched Psych-Info and Medline databases using a systematic search strategy and identified 29 articles. We found preliminary evidence that some specific strategies may enhance the effects of exposure, such as dropping safety behaviours, parents and therapists discouraging avoidance, and the use of homework. However, not one significant finding was replicated by another study for the same timepoint using the same methodology. To a large degree, this lack of replication reflects a limited number of studies combined with a lack of consistency across studies around conceptualisations, methodological approaches, and outcome measures making it difficult to make meaningful comparisons between studies and draw firm conclusions. Examination is needed of a wide range of theoretically-driven potential optimisation strategies using methodologically robust, preclinical studies with children and young people. Furthermore, the methods used in future research must enable comparisons across studies and explore developmental differences in the effects of particular optimisation strategies.
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Affiliation(s)
- Hannah Plaisted
- School of Psychology, University of Birmingham, Birmingham, UK
- School of Psychology and Clinical Language Sciences, University of Reading, Reading, UK
| | - Polly Waite
- School of Psychology and Clinical Language Sciences, University of Reading, Reading, UK.
- Department of Experimental Psychology & Department of Psychiatry, University of Oxford, Oxford, UK.
| | - Kate Gordon
- Berkshire Healthcare NHS Foundation Trust, Berkshire, UK
| | - Cathy Creswell
- Department of Experimental Psychology & Department of Psychiatry, University of Oxford, Oxford, UK
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15
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Piacentini J, Wu M, Rozenman M, Bennett S, McGuire J, Nadeau J, Lewin A, Sookman D, Lindsey Bergman R, Storch E, Peris T. Knowledge and competency standards for specialized cognitive behavior therapy for pediatric obsessive-compulsive disorder. Psychiatry Res 2021; 299:113854. [PMID: 33765492 DOI: 10.1016/j.psychres.2021.113854] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 03/01/2021] [Indexed: 02/07/2023]
Abstract
Although exposure-based cognitive behavior therapy (CBT) and pharmacotherapy have demonstrated efficacy for obsessive-compulsive disorder (OCD), the lack of clinicians effectively trained in these treatments significantly limit effective intervention options for affected youth. This is very unfortunate since child onset is reported by 50% of adults with OCD. To ameliorate this serious global issue the 14 nation International Obsessive-Compulsive Disorders Accreditation Task Force (ATF) of The Canadian Institute for Obsessive Compulsive Disorders (CIOCD) has developed knowledge and competency standards recommended for specialized treatments for OCD through the lifespan. Currently available guidelines are considered by experts to be essential but insufficient because there are not enough clinicians with requisite knowledge and competencies to effectively treat OCD. This manuscript presents knowledge and competency standards recommended for specialized cognitive behavior therapy (CBT) for pediatric OCD, derived from comprehensive literature review and expert synthesis. In addition to standards covering the elements of individual CBT-based assessment and treatment, family and school interventions are addressed given the critical role these domains play in the psychosocial development of youths. The ATF standards presented in these phase two papers will be foundational to the upcoming development of certification (individuals) and accreditation (sites) for specialized treatments in OCD through the lifespan.
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Affiliation(s)
- John Piacentini
- Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA USA.
| | - Monica Wu
- Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA USA.
| | | | - Shannon Bennett
- Department of Psychiatry, Weill Cornell Medical College, NY, NY USA
| | - Joseph McGuire
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Josh Nadeau
- Department of Pediatrics, University of South Florida, St. Petersburg, FL, and Rogers Memorial Hospital, Oconomowoc, WI, USA
| | - Adam Lewin
- Departments of Psychiatry and Behavioral Neurosciences and Pediatrics, University of South Florida, St. Petersburg, FL, USA
| | - Debbie Sookman
- Department of Psychology, McGill University Health Center, and Department of Psychiatry, McGill University, Montreal, Quebec, CANADA
| | | | - Eric Storch
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX USA
| | - Tara Peris
- Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA USA
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16
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Benito KG, Machan J, Freeman JB, Garcia AM, Walther M, Frank H, Wellen B, Stewart E, Edmunds J, Sapyta J, Franklin ME. Therapist Behavior During Exposure Tasks Predicts Habituation and Clinical Outcome in Three Randomized Controlled Trials for Pediatric OCD. Behav Ther 2021; 52:523-538. [PMID: 33990231 PMCID: PMC8124089 DOI: 10.1016/j.beth.2020.07.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 07/07/2020] [Accepted: 07/12/2020] [Indexed: 12/13/2022]
Abstract
This study measured therapist behaviors in relation to subsequent habituation within exposure tasks, and also tested their direct and indirect relationships (via habituation) with clinical outcomes of exposure therapy. We observed 459 videotaped exposure tasks with 111 participants in three clinical trials for pediatric obsessive-compulsive disorder (POTS trials). Within exposure tasks, therapist behaviors and patient fear were coded continuously. Outcomes were habituation and posttreatment change in symptom severity, global improvement, and treatment response. More therapist behaviors that encourage approach-and less use of accommodation, unrelated talk, and externalizing language-predicted greater subsequent habituation during individual exposure tasks (exposure-level), and also predicted improved patient clinical outcomes via higher "total dose" of habituation across treatment (patient-level indirect effect). For six of seven therapist behaviors analyzed, the relationship with subsequent habituation within exposure differed by patient fear (low, moderate, or high) at the time the behavior was used. Two therapist behaviors had direct effects in the opposite direction expected; more unrelated talk and less intensifying were associated with greater patient symptom reduction. Results shed light on the "black box" of in-session exposure activities and point to specific therapist behaviors that may be important for clinical outcomes. These behaviors might be best understood in the context of changing patient fear during exposure tasks. Future studies should test whether therapist behaviors can be experimentally manipulated to produce improvement in clinical outcomes.
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Affiliation(s)
| | - Jason Machan
- Lifespan Biostatistics Core, Lifespan Hospitals; Warren Alpert Medical School of Brown University; University of Rhode Island
| | | | | | | | | | | | | | - Julie Edmunds
- Massachusetts General Hospital, Harvard Medical School
| | | | - Martin E Franklin
- Perelman School of Medicine, University of Pennsylvania, & Rogers Behavioral Health
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17
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Jensen S, Højgaard DRMA, Hybel KA, Mortensen EL, Skarphedinsson G, Melin K, Ivarsson T, Nissen JB, Weidle B, Valderhaug R, Torp NC, Dahl K, Compton S, Thomsen PH. Distinct trajectories of long-term symptom severity in pediatric obsessive-compulsive disorder during and after stepped-care treatment. J Child Psychol Psychiatry 2020; 61:969-978. [PMID: 31736082 DOI: 10.1111/jcpp.13155] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 09/02/2019] [Accepted: 10/09/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND First-line treatments for pediatric obsessive-compulsive disorder (OCD) include exposure-based cognitive-behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs). No studies have thus far identified distinct classes and associated predictors of long-term symptom severity during and after treatment. Yet, these could form the basis for more personalized treatment in pediatric OCD. METHOD The study included 269 OCD patients aged 7-17 years from the Nordic Long-term OCD Treatment Study (NordLOTS). All participants received stepped-care treatment starting with 14 weekly sessions of manualized CBT. Nonresponders were randomized to either prolonged CBT or SSRIs. Symptom severity was assessed using the Children's Yale-Brown Obsessive-Compulsive Scale at seven time points from pre- to post-treatment and over a three-year follow-up. Latent class growth analysis (LCGA) was performed to identify latent classes of symptom severity trajectories. Univariate and multivariate analyses were used to detect differences between classes and identify predictors of trajectory class membership including several clinical and demographic variables. TRIAL REGISTRY Nordic Long-term Obsessive-Compulsive Disorder (OCD) Treatment Study; www.controlled-trials.com; ISRCTN66385119. RESULTS Three LCGA classes were identified: (a) acute, sustained responders (54.6%); (b) slow, continued responders (23.4%); and (c) limited long-term responders (21.9%). Class membership was predicted by distinct baseline characteristics pertaining to age, symptom severity, contamination/cleaning and anxiety symptoms. CONCLUSIONS The LCGA suggests three distinct trajectory classes of long-term symptom severity during and after treatment in pediatric OCD with different clinical profiles at pretreatment. The results point to required clinical attention for adolescent patients with contamination/cleaning and anxiety symptoms who do not show convincing responses to first-line treatment even though they may have reached the established cutoff for treatment response.
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Affiliation(s)
- Sanne Jensen
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Psychiatry, Aarhus, Denmark
| | - Davíð R M A Højgaard
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Psychiatry, Aarhus, Denmark
| | - Katja A Hybel
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Psychiatry, Aarhus, Denmark
| | - Erik Lykke Mortensen
- Department of Public Health and Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark
| | | | - Karin Melin
- Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Child and Adolescent Psychiatry, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Tord Ivarsson
- Institute of Neuroscience and Physiology, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Regional Centre for Child and Youth Mental Health and Child Welfare Central Norway, Norwegian University of Science and Technology, Trondheim, Norway
| | - Judith Becker Nissen
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Psychiatry, Aarhus, Denmark
| | - Bernhard Weidle
- Regional Centre for Child and Youth Mental Health and Child Welfare Central Norway, Norwegian University of Science and Technology, Trondheim, Norway
| | - Robert Valderhaug
- Regional Centre for Child and Youth Mental Health and Child Welfare Central Norway, Norwegian University of Science and Technology, Trondheim, Norway
| | - Nor Christian Torp
- Division of Mental Health and Addiction, Department of Child and Adolescent Psychiatry, Vestre Viken Hospital, Drammen, Norway
| | - Kitty Dahl
- Centre for Child and Adolescent Mental Health, Eastern and Southern Norway, Oslo, Norway
| | - Scott Compton
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Per Hove Thomsen
- Department of Child and Adolescent Psychiatry, Aarhus University Hospital, Psychiatry, Aarhus, Denmark
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18
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Geller DA, McGuire JF, Orr SP, Small BJ, Murphy TK, Trainor K, Porth R, Wilhelm S, Storch EA. Fear extinction learning as a predictor of response to cognitive behavioral therapy for pediatric obsessive compulsive disorder. J Anxiety Disord 2019; 64:1-8. [PMID: 30852257 PMCID: PMC7422704 DOI: 10.1016/j.janxdis.2019.02.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 01/22/2019] [Accepted: 02/26/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND While cognitive behavior therapy (CBT) is an effective treatment for many children and adolescents with Obsessive Compulsive Disorder (OCD), therapeutic response is variable. Fear conditioning and extinction are central constructs underlying exposure-based CBT. Fear extinction learning assessed prior to CBT may be a useful predictor of CBT response for guiding treatment decisions. METHODS Sixty-four youth who participated in a randomized placebo-controlled trial of CBT with and without d-cycloserine (DCS) completed a fear conditioning task. Skin conductance response (SCR) scores were used to measure fear acquisition and extinction to determine whether extinction learning could predict CBT response. RESULTS CBT responders and non-responders appeared to acquire conditioned fear SCRs in a similar manner. However, differences between treatment responders and non-responders emerged during the extinction phase. A responder (responder, non-responder) by conditioned stimulus type (CS+, CS-) interaction showed that CBT responders differentiated the stimulus paired with (CS+) and without (CS-) the unconditioned stimulus correctly during early and late extinction, whereas the CBT non-responders did not (p = .004). CONCLUSIONS While the small sample size makes conclusions tentative, this study supports an emerging literature that differential fear extinction may be an important factor underlying clinical correlates of pediatric OCD, including CBT response.
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Affiliation(s)
- Daniel A Geller
- Massachusetts General Hospital, 185 Cambridge Street, Suite 2000, Boston, MA, 02114, United States; Harvard University Medical School, Boston, MA, United States.
| | - Joseph F McGuire
- Division of Child and Adolescent Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Scott P Orr
- Massachusetts General Hospital, 185 Cambridge Street, Suite 2000, Boston, MA, 02114, United States; Harvard University Medical School, Boston, MA, United States.
| | - Brent J Small
- School of Aging Studies, University of South Florida, 13301 Bruce B Downs Blvd, Tampa, FL, 33620, United States.
| | - Tanya K Murphy
- Department of Pediatrics, University of South Florida, Rothman Center for Neuropsychiatry, United States; Department of Psychiatry & Behavioral Neurosciences, University of South Florida, United States
| | - Kathleen Trainor
- Massachusetts General Hospital, 185 Cambridge Street, Suite 2000, Boston, MA, 02114, United States.
| | - Rachel Porth
- Massachusetts General Hospital, 185 Cambridge Street, Suite 2000, Boston, MA, 02114, United States.
| | - Sabine Wilhelm
- Massachusetts General Hospital, 185 Cambridge Street, Suite 2000, Boston, MA, 02114, United States; Harvard University Medical School, Boston, MA, United States.
| | - Eric A Storch
- Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, 1977 Butler Blvd, Suite 400, Houston 77030, TX, United States.
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19
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Guzick AG, Reid AM, Balkhi AM, Geffken GR, McNamara JPH. That Was Easy! Expectancy Violations During Exposure and Response Prevention for Childhood Obsessive-Compulsive Disorder. Behav Modif 2018; 44:319-342. [PMID: 30449128 DOI: 10.1177/0145445518813624] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Violating expectancies during exposure therapy is proposed to promote inhibitory learning and improved treatment outcomes. Because people tend to overestimate how distressing emotionally challenging situations will be, violating expectations of distress may be an intuitive way to promote treatment outcome during exposure-based cognitive-behavioral therapy (CBT). This study evaluated overpredictions of distress during exposure tasks in 33 youth with obsessive-compulsive disorder (OCD; ages 8-17) participating in CBT. Youth with more variable prediction accuracy and a higher proportion of overpredictions experienced more rapid symptom reduction, b = -0.29, p = .002. Underpredictions were less common toward the end of therapy as youth experienced less severe OCD, b = 0.12, p= .001. Findings suggest that although youth often accurately predict the intensity of exposure, overpredictions are common as well. The frequency of these overpredictions promoted treatment outcome, supporting expectancy violations as one indicator of inhibitory learning during exposure therapy.
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20
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Coercive and disruptive behaviors mediate group cognitive-behavioral therapy response in pediatric obsessive-compulsive disorder. Compr Psychiatry 2018; 86:74-81. [PMID: 30081210 DOI: 10.1016/j.comppsych.2018.07.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 06/12/2018] [Accepted: 07/13/2018] [Indexed: 01/01/2023] Open
Abstract
PURPOSE Coercive and disruptive behaviors (CDBs) are commonplace in pediatric obsessive-compulsive disorder (OCD) and are associated with increased disorder impact and reduced treatment response. Prior research suggests that CDBs mediate the cross-sectional relationship between family accommodation and OCD symptom severity; however, the impact of reducing CDBs on other treatment outcomes has yet to be studied. METHODS Participants comprised 49 OCD-affected youth (42.9% male, Mage at baseline = 13.7) and their parent(s) who completed a 12-week, group family-based cognitive-behavioral treatment at an OCD specialty clinic. Outcomes included parent-report measures of CDBs, family accommodation, symptom severity, and both child- and family-level impairment. Descriptive, correlation, and regression analyses were followed by tests of indirect effects (mediation). RESULTS Changes in all outcome variables had moderate to strong correlations with each other. As hypothesized, CDB decreases predicted positive changes in OCD severity as well as in child and family impairment. Further, whereas improvement in OCD severity predicted changes in child and family impairment, improvements in family accommodation were not directly predictive of any outcomes. Consistent with hypotheses, changes in CDBs mediated relationships between changes in accommodation and child- and family-level impairment, as well as relationships between changes in OCD severity and both levels of impairment. Additional exploratory analyses found that changes in symptom severity significantly mediated relationships between changes in CDBs and both levels of impairments. CONCLUSIONS Findings suggest that attention to reducing CDBs is warranted in the treatment of pediatric OCD, and that accommodation reductions lead to meaningful improvements in child and family functioning only when CDBs and/or symptoms are also reduced. Future family-based treatments may benefit from inclusion of components specifically targeting CDBs that occur within the context of accommodating OCD symptoms.
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21
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Freeman J, Benito K, Herren J, Kemp J, Sung J, Georgiadis C, Arora A, Walther M, Garcia A. Evidence Base Update of Psychosocial Treatments for Pediatric Obsessive-Compulsive Disorder: Evaluating, Improving, and Transporting What Works. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY 2018; 47:669-698. [DOI: 10.1080/15374416.2018.1496443] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Jennifer Freeman
- Alpert Medical School of Brown University, Pediatric Anxiety Research Center, Bradley Hospital
| | - Kristen Benito
- Alpert Medical School of Brown University, Pediatric Anxiety Research Center, Bradley Hospital
| | - Jennifer Herren
- Alpert Medical School of Brown University, Pediatric Anxiety Research Center, Bradley Hospital
| | - Joshua Kemp
- Alpert Medical School of Brown University, Pediatric Anxiety Research Center, Bradley Hospital
| | - Jenna Sung
- Alpert Medical School of Brown University, Pediatric Anxiety Research Center, Bradley Hospital
| | - Christopher Georgiadis
- Alpert Medical School of Brown University, Pediatric Anxiety Research Center, Bradley Hospital
| | - Aishvarya Arora
- Alpert Medical School of Brown University, Pediatric Anxiety Research Center, Bradley Hospital
| | - Michael Walther
- Alpert Medical School of Brown University, Pediatric Anxiety Research Center, Bradley Hospital
| | - Abbe Garcia
- Alpert Medical School of Brown University, Pediatric Anxiety Research Center, Bradley Hospital
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22
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Benito KG, Machan J, Freeman JB, Garcia AM, Walther M, Frank H, Wellen B, Stewart E, Edmunds J, Kemp J, Sapyta J, Franklin M. Measuring fear change within exposures: Functionally-defined habituation predicts outcome in three randomized controlled trials for pediatric OCD. J Consult Clin Psychol 2018; 86:615-630. [PMID: 29939055 PMCID: PMC6023553 DOI: 10.1037/ccp0000315] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE This study measured a variety of within-exposure fear changes and tested the relationship of each with treatment outcomes in exposure therapy. METHOD We coded 459 videotaped exposure tasks from 111 participants in 3 clinical trials for pediatric obsessive-compulsive disorder (OCD; POTS trials). Within exposures, fear level was observed continuously and alongside exposure process. Fear change metrics of interest were selected for relevance to mechanistic theory. Fear decreases were classified by function; nonhabituation decreases were associated with observed nonlearning processes (e.g., avoidance), whereas habituation decreases appeared to result from an internal and indirect process. Outcomes were posttreatment change in symptom severity, global improvement, and treatment response. RESULTS Greater cumulative habituation across treatment was associated with larger reductions in symptom severity, greater global improvement, and increased odds of treatment response. Fear activation, fear variability, and nonhabituation fear decreases did not predict any outcomes. Exploratory analyses examined fear changes during habituation and nonhabituation exposures; higher peak fear during nonhabituation exposures was associated with attenuated global improvement. CONCLUSIONS Habituation is conceptually consistent with multiple mechanistic theories and should continue to be investigated as a practical marker of initial extinction learning and possible moderator of the relationship between fear activation and outcome. Results support the importance of functional and frequent fear measurement during exposures, and discussion considers implications of these findings for future studies aiming to understand learning during exposure and improve exposure delivery. (PsycINFO Database Record
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Affiliation(s)
- Kristen G. Benito
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University
| | - Jason Machan
- Lifespan Biostatistics Core, Lifespan Hospitals
- Departments of Orthopaedics & Surgery, Warren Alpert Medical School of Brown University
- Department of Psychology, University of Rhode Island
| | - Jennifer B. Freeman
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University
| | - Abbe M. Garcia
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University
| | - Michael Walther
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University
| | | | | | - Elyse Stewart
- Department of Psychology, State University of New York at Binghamton
| | - Julie Edmunds
- Massachusetts General Hospital, Harvard Medical School
| | - Joshua Kemp
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University
| | - Jeffrey Sapyta
- Psychiatry and Behavioral Sciences, Duke University Medical Center
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Thorsen AL, Kvale G, Hansen B, van den Heuvel OA. Symptom dimensions in obsessive-compulsive disorder as predictors of neurobiology and treatment response. ACTA ACUST UNITED AC 2018; 5:182-194. [PMID: 30237966 DOI: 10.1007/s40501-018-0142-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Purpose of review Specific symptom dimensions of obsessive-compulsive disorder (OCD) have been suggested as an approach to reduce the heterogeneity of obsessive-compulsive disorder, predict treatment outcome, and relate to brain structure and function. Here, we review studies addressing these issues. Recent findings The contamination and symmetry/ordering dimensions have not been reliably associated with treatment outcome. Some studies found that greater severity of sexual/aggressive/religious symptoms predicted a worse outcome after cognitive behavioral therapy (CBT) and a better outcome after serotonin reuptake inhibitors (SRIs). Contamination symptoms have been related to increased amygdala and insula activation in a few studies, while sexual/aggressive/religious symptoms have also been related to more pronounced alterations in the function and structure of the amygdala. Increased pre-treatment limbic responsiveness has been related to better outcomes of CBT, but most imaging studies show important limitations and replication in large-scale studies is needed. We review possible reasons for the strong limbic involvement of the amygdala in patients with more sexual/aggressive/religious symptoms, in relation to their sensitivity to CBT. Summary Symptom dimensions may predict treatment outcome, and patients with sexual/religious/aggressive symptoms are at a greater risk of not starting or delaying treatment. This is likely partly due to more shame and perceived immorality which is also related to stronger amygdala response. Competently delivered CBT is likely to help these patients improve to the same degree as patients with other symptoms.
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Affiliation(s)
- Anders Lillevik Thorsen
- OCD-team, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Psychology, University of Bergen, Bergen, Norway.,Department of Anatomy & Neurosciences, VU university medical center (VUmc), Amsterdam, The Netherlands
| | - Gerd Kvale
- OCD-team, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Psychology, University of Bergen, Bergen, Norway
| | - Bjarne Hansen
- OCD-team, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Psychology, University of Bergen, Bergen, Norway
| | - Odile A van den Heuvel
- OCD-team, Haukeland University Hospital, Bergen, Norway.,Department of Anatomy & Neurosciences, VU university medical center (VUmc), Amsterdam, The Netherlands.,Department of Psychiatry, VUmc, Amsterdam, The Netherlands.,Neuroscience Amsterdam, Amsterdam, The Netherlands
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24
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An Inhibitory Learning Approach to Cognitive-Behavioral Therapy for Children and Adolescents. COGNITIVE AND BEHAVIORAL PRACTICE 2018; 26:214-224. [PMID: 31205406 DOI: 10.1016/j.cbpra.2017.12.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Although exposure-based cognitive-behavioral therapy (CBT) is efficacious for childhood anxiety and obsessive-compulsive disorder (OCD), many youth do not adequately respond to treatment. Extinction learning is an important process in exposure-based CBT. However, youth with anxiety disorders and OCD exhibit impairments in extinction processes that are best characterized by deficits in inhibitory learning. Therefore, the utilization of strategies to optimize inhibitory learning during exposures may compensate for these deficits, thereby maximizing extinction processes and producing more robust treatment outcomes for exposure-based CBT. This paper reviews several strategies to optimize inhibitory learning in youth with anxiety disorders and OCD, and presents practical examples for each strategy. This paper also highlights the difference between inhibitory learning-based exposures and prior conceptual approaches to exposure therapy in clinical practice. It concludes with a discussion of future directions for clinical research on inhibitory learning and exposure-based CBT in youth.
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25
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Peris TS, Caporino NE, O'Rourke S, Kendall PC, Walkup JT, Albano AM, Bergman RL, McCracken JT, Birmaher B, Ginsburg GS, Sakolsky D, Piacentini J, Compton SN. Therapist-Reported Features of Exposure Tasks That Predict Differential Treatment Outcomes for Youth With Anxiety. J Am Acad Child Adolesc Psychiatry 2017; 56:1043-1052. [PMID: 29173738 DOI: 10.1016/j.jaac.2017.10.001] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 08/30/2017] [Accepted: 10/03/2017] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Exposure tasks are recognized widely as a key component of cognitive-behavioral therapy (CBT) for child and adolescent anxiety. However, little research has examined specific exposure characteristics that predict outcomes for youth with anxiety and that may guide its application in therapy. METHOD This study draws on a sample of 279 children and adolescents (48.4% male; 79.6% white) with a principal anxiety disorder who received 14 sessions of CBT, either alone or in combination with medication, through the Child/adolescent Anxiety Multimodal treatment Study (CAMS). The present study examines therapist-reported quantity, difficulty level, compliance, and mastery of exposure tasks as they related to CBT response (i.e., Clinical Global Impressions-Improvement ratings). Secondary treatment outcomes included reduction in anxiety symptom severity on the Pediatric Anxiety Rating Scale, global impairment measured via the Children's Global Assessment Scale, and parent-report of anxiety-specific functional impairment on the Child Anxiety Impairment Scale. RESULTS Regression analyses indicated a dose-response relationship between therapist-reported quantity of exposure and independent evaluations of treatment outcome, with more time devoted to exposure linked to better outcomes. Similarly, greater time spent on more difficult (rather than mild or moderate) exposure tasks predicted better outcomes, as did therapist ratings of child compliance and mastery. CONCLUSION The present findings highlight the importance of challenging children and adolescents with difficult exposure tasks and of collaborating to ensure compliance and mastery.
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Affiliation(s)
- Tara S Peris
- UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA.
| | | | | | | | | | - Anne Marie Albano
- New York State Psychiatric Institute-Columbia University Medical Center, New York
| | - R Lindsey Bergman
- UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA
| | - James T McCracken
- UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA
| | - Boris Birmaher
- Western Psychiatric Institute and Clinic-University of Pittsburgh Medical Center, Pittsburgh
| | | | - Dara Sakolsky
- Western Psychiatric Institute and Clinic-University of Pittsburgh Medical Center, Pittsburgh
| | - John Piacentini
- UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA
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26
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Crawford EA, Frank HE, Palitz SA, Davis JP, Kendall PC. Process Factors Associated with Improved Outcomes in CBT for Anxious Youth: Therapeutic Content, Alliance, and Therapist Actions. COGNITIVE THERAPY AND RESEARCH 2017. [DOI: 10.1007/s10608-017-9864-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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27
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Fiat AE, Cook CR, Zhang Y, Renshaw TL, DeCano P, Merrick JS. Mentoring to Promote Courage and Confidence Among Elementary School Students With Internalizing Problems: A Single-Case Design Pilot Study. JOURNAL OF APPLIED SCHOOL PSYCHOLOGY 2017. [DOI: 10.1080/15377903.2017.1292975] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Aria E. Fiat
- Department of Educational Psychology, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
| | - Clayton R. Cook
- Department of Educational Psychology, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
| | - Yanchen Zhang
- Department of Educational Psychology, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
| | - Tyler L. Renshaw
- Department of Psychology, Louisiana State University, Baton Rouge, Louisiana, USA
| | - Polocarpio DeCano
- Department of Educational Psychology, University of Washington, Seattle, Washington, USA
| | - Jillian S. Merrick
- Institute of Child Development, University of Minnesota, Minneapolis, Minnesota, USA
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28
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Jordan C, Reid AM, Guzick AG, Simmons J, Sulkowski ML. When Exposures Go Right: Effective Exposure-Based Treatment for Obsessive–Compulsive Disorder. JOURNAL OF CONTEMPORARY PSYCHOTHERAPY 2017. [DOI: 10.1007/s10879-016-9339-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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29
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Geller DA, McGuire JF, Orr SP, Pine DS, Britton JC, Small BJ, Murphy TK, Wilhelm S, Storch EA. Fear conditioning and extinction in pediatric obsessive-compulsive disorder. Ann Clin Psychiatry 2017; 29:17-26. [PMID: 28207912 PMCID: PMC5964984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
BACKGROUND Fear acquisition and extinction are central constructs in the cognitive-behavioral model of obsessive-compulsive disorder (OCD), which underlies exposure-based cognitive-behavioral therapy. Youths with OCD may have impairments in fear acquisition and extinction that carry treatment implications. METHODS Eighty youths (39 OCD, 41 healthy controls [HC]) completed clinical interviews, rating scales, and a differential conditioning task that included habituation, acquisition, and extinction phases. Skin conductance response (SCR) served as the primary dependent measure. RESULTS During habituation, participants with OCD exhibited a stronger orienting SCR to initial stimuli relative to HC participants. During acquisition, differential fear conditioning was observed for both groups as evidenced by larger SCRs to the visual conditioned stimulus paired with an aversive unconditioned stimulus (CS+) compared with a CS-; OCD participants exhibited a larger SCR to the CS+ relative to HC participants. The absolute magnitude of the unconditioned fear response was significantly larger in participants with OCD, compared with HC participants. During extinction, OCD participants continued to exhibit a differential SCR to the CS+ and CS-, whereas HC participants exhibited diminished SCR to both stimuli. CONCLUSIONS Participants with OCD exhibit a different pattern of fear extinction relative to HC participants, suggestive of greater fear acquisition and impaired inhibitory learning.
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Affiliation(s)
- Daniel A Geller
- General Hospital Harvard University Medical School, Boston, MA, USA. E-mail:
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30
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Vloet TD, Herpertz-Dahlmann B, Simons M. [New developments in the psychotherapeutic and pharmacological treatment of pediatric obsessivecompulsive disorder]. ZEITSCHRIFT FUR KINDER- UND JUGENDPSYCHIATRIE UND PSYCHOTHERAPIE 2017; 45:9-22. [PMID: 27299378 DOI: 10.1024/1422-4917/a000445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Den Goldstandard in der Behandlung von Zwangsstörungen im Kindes- und Jugendalter stellen die kognitiv-behaviorale Therapie sowie die Medikation mit selektiven Serotonin-Wiederaufnahmehemmern dar. In den letzten Jahren wurden vermehrt auch alternative psychotherapeutische und v. a. psychopharmakologische Behandlungsstrategien untersucht, die möglicherweise bei therapieresistenten Zwangsstörungen erfolgreich sein könnten. Die vorliegende Übersichtsarbeit fasst diese neuen Entwicklungen zusammen, wobei ein Schwerpunkt auf expositionsbezogene psychotherapeutische bzw. pharmakologische Ansätze im glutamatergen System gelegt wurde. Hinsichtlich neuer pharmakologischer Behandlungsoptionen bei Kindern und Jugendlichen unterstreicht die derzeitige Datenlage, v. a. im Hinblick auf den Grad der nachgewiesenen Evidenz sowie mögliche unerwünschte Nebenwirkungen, die Bedeutung einer optimal durchgeführten Kombinationstherapie. Dabei kann diese einer Monotherapie mit kognitiv-behavioraler Therapie im Einzelfall überlegen sein. Eine grundsätzliche Überlegenheit der Kombinationstherapie ist derzeit allerdings nicht nachgewiesen.
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Affiliation(s)
- Timo D Vloet
- 1 Klinik für Psychiatrie, Psychosomatik und Psychotherapie des Kindes- und Jugendalters, Universitätsklinikum der RWTH Aachen
- 2 Lehr- und Forschungsgebiet Klinische Neuropsychologie des Kindes- und Jugendalters an der Klinik für Psychiatrie, Psychosomatik und Psychotherapie des Kindes und Jugendalters, Universitätsklinikum der RWTH Aachen
| | - Beate Herpertz-Dahlmann
- 1 Klinik für Psychiatrie, Psychosomatik und Psychotherapie des Kindes- und Jugendalters, Universitätsklinikum der RWTH Aachen
| | - Michael Simons
- 1 Klinik für Psychiatrie, Psychosomatik und Psychotherapie des Kindes- und Jugendalters, Universitätsklinikum der RWTH Aachen
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31
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McGuire JF, Orr SP, Essoe JKY, McCracken JT, Storch EA, Piacentini J. Extinction learning in childhood anxiety disorders, obsessive compulsive disorder and post-traumatic stress disorder: implications for treatment. Expert Rev Neurother 2016; 16:1155-74. [PMID: 27275519 PMCID: PMC5967402 DOI: 10.1080/14737175.2016.1199276] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Threat conditioning and extinction play an important role in anxiety disorders, obsessive compulsive disorder (OCD), and post-traumatic stress disorder (PTSD). Although these conditions commonly affect children, threat conditioning and extinction have been primarily studied in adults. However, differences in phenomenology and neural architecture prohibit the generalization of adult findings to youth. AREAS COVERED A comprehensive literature search using PubMed and PsycInfo was conducted to identify studies that have used differential conditioning tasks to examine threat acquisition and extinction in youth. The information obtained from this review helps to clarify the influence of these processes on the etiology and treatment of youth with OCD, PTSD and other anxiety disorders. Thirty studies of threat conditioning and extinction were identified Expert commentary: Youth with anxiety disorders, OCD, and PTSD have largely comparable threat acquisition relative to unaffected controls, with some distinctions noted for youth with PTSD or youth who have suffered maltreatment. However, impaired extinction was consistently observed across youth with these disorders and appears to be consistent with deficiencies in inhibitory learning. Incorporating strategies to improve inhibitory learning may improve extinction learning within extinction-based treatments like cognitive behavioral therapy (CBT). Strategies to improve inhibitory learning in CBT are discussed.
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Affiliation(s)
- Joseph F. McGuire
- Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles
| | - Scott P. Orr
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | | | - James T. McCracken
- Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles
| | - Eric A. Storch
- Department of Pediatrics, University of South Florida
- Departments of Psychiatry and Behavioral Neurosciences, University of South Florida
- Department of Health Policy and Management, University of South Florida
- Rogers Behavioral Health – Tampa Bay
- All Children's Hospital, Johns Hopkins Medicine, St. Petersburg, FL
| | - John Piacentini
- Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles
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32
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McGuire JF, Orr SP, Wu MS, Lewin AB, Small BJ, Phares V, Murphy TK, Wilhelm S, Pine DS, Geller D, Storch EA. FEAR CONDITIONING AND EXTINCTION IN YOUTH WITH OBSESSIVE-COMPULSIVE DISORDER. Depress Anxiety 2016; 33:229-37. [PMID: 26799264 PMCID: PMC5701569 DOI: 10.1002/da.22468] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Revised: 11/18/2015] [Accepted: 01/03/2016] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Fear acquisition and extinction are central constructs in the cognitive-behavioral model of obsessive-compulsive disorder (OCD), which underlies exposure-based cognitive-behavioral therapy (CBT). Youth with OCD may have impairments in fear acquisition and extinction that carry treatment implications. We examined these processes using a differential conditioning procedure. METHODS Forty-one youth (19 OCD, 22 community comparisons) completed a battery of clinical interviews, rating scales, and a differential conditioning task that included habituation, acquisition, and extinction phases. Skin conductance response (SCR) served as the primary dependent measure. RESULTS During habituation, no difference between groups was observed. During acquisition, differential fear conditioning was observed across participants as evidenced by larger SCRs to the CS+ compared to CS-; there were no between-group differences. Across participants, the number and frequency of OCD symptoms and anxiety severity was associated with greater reactivity to stimuli during acquisition. During extinction, a three-way interaction and follow-up tests revealed that youth with OCD showed a different pattern of SCR extinction compared to the community comparison group. CONCLUSIONS Youth with OCD exhibit a different pattern of fear extinction relative to community comparisons. This may be attributed to impaired inhibitory learning and contingency awareness in extinction. Findings suggest the potential benefit of utilizing inhibitory-learning principles in CBT for youth with OCD, and/or augmentative retraining interventions prior to CBT to reduce threat bias and improve contingency detection.
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Affiliation(s)
- Joseph F. McGuire
- Semel Institute of Neuroscience and Human Behavior, University of California Los Angeles
| | - Scott P. Orr
- Massachusetts General Hospital and Harvard Medical School
| | - Monica S. Wu
- Department of Psychology, University of South Florida,Department of Pediatrics, University of South Florida
| | - Adam B. Lewin
- Department of Psychology, University of South Florida,Department of Pediatrics, University of South Florida,Departments of Psychiatry and Behavioral Neuroscience, University of South Florida,All Children's Hospital, Johns Hopkins Medicine
| | | | - Vicky Phares
- Department of Psychology, University of South Florida
| | - Tanya K. Murphy
- Department of Pediatrics, University of South Florida,Departments of Psychiatry and Behavioral Neuroscience, University of South Florida,All Children's Hospital, Johns Hopkins Medicine
| | - Sabine Wilhelm
- Massachusetts General Hospital and Harvard Medical School
| | | | - Daniel Geller
- Massachusetts General Hospital and Harvard Medical School
| | - Eric A. Storch
- Department of Psychology, University of South Florida,Department of Pediatrics, University of South Florida,Departments of Psychiatry and Behavioral Neuroscience, University of South Florida,All Children's Hospital, Johns Hopkins Medicine,Rogers Behavioral Health – Tampa Bay,Department of Health Policy and Management, University of South Florida
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33
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Personalizing the Treatment of Pediatric Obsessive-Compulsive Disorder: Evidence for Predictors and Moderators of Treatment Outcomes. Curr Behav Neurosci Rep 2016. [DOI: 10.1007/s40473-016-0066-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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34
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Olatunji BO, Rosenfield D, Monzani B, Krebs G, Heyman I, Turner C, Isomura K, Mataix-Cols D. EFFECTS OF HOMEWORK COMPLIANCE ON COGNITIVE-BEHAVIORAL THERAPY WITH D-CYCLOSERINE AUGMENTATION FOR CHILDREN WITH OBSESSIVE COMPULSIVE DISORDER. Depress Anxiety 2015; 32:935-43. [PMID: 26372401 DOI: 10.1002/da.22423] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Revised: 08/04/2015] [Accepted: 08/14/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The present study examined the effects of homework compliance on outcome from cognitive behavioral therapy (CBT) for children with obsessive-compulsive disorder (OCD) and the extent to which these effects differ as a function of augmentation of CBT with D-cycloserine (DCS). METHODS Twenty-seven youth with OCD were randomized to either 50 mg DCS or placebo (PBO) administered immediately after each of 10 CBT sessions, primarily consisting of exposure and ritual prevention (ERP). Independent evaluators assessed OCD severity using the Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) at the start of each session. Compliance with between-session ERP assignments was also assessed at the start of each session using the Patient ERP Adherence Scale (PEAS). RESULTS Greater homework compliance between the previous session and the current session was related to lower CY-BOCS at the current session. However, the relation between homework compliance and CY-BOCS varied by treatment condition. Higher homework compliance was related to lower CY-BOCS for participants in the DCS condition, but not for participants in the PBO condition. Furthermore, participants receiving DCS were estimated to have significantly lower CY-BOCS than those given PBO among those with the highest levels of homework compliance. CONCLUSIONS DCS may more effectively facilitate the effects of CBT for youth with OCD when patients are compliant with prescribed homework. Theoretical and clinical implications are discussed.
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Affiliation(s)
- Bunmi O Olatunji
- Department of Psychology, Vanderbilt University, Nashville, Tennessee
| | - David Rosenfield
- Department of Psychology, Southern Methodist University, Dallas, Texas
| | - Benedetta Monzani
- Institute of Psychiatry, Psychology & Neuroscience, King's College, London, UK
| | - Georgina Krebs
- Institute of Psychiatry, Psychology & Neuroscience, King's College, London, UK
| | - Isobel Heyman
- Dept of Neurosciences & Mental Health, Institute of Child Health, London, UK
| | - Cynthia Turner
- School of Psychology, University of Queensland, Australia
| | - Kayoko Isomura
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - David Mataix-Cols
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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