Predictors of quality of life and functional impairment in obsessive-compulsive disorder

Urged to feel certain again: The role of emotion-related impulsivity on the relationships between intolerance of uncertainty and OCD symptom severity

OBJECTIVES

Obsessive-compulsive disorder (OCD) is a debilitating mental disorder characterized by persistent and intrusive thoughts accompanied by repetitive mental or physical acts. While both intolerance of uncertainty and emotion-related impulsivity have been consistently evidenced as cognitive risk factors of OCD, no studies have considered their joint effects. The current study examined the interaction between intolerance of uncertainty and two forms of emotion-related impulsivity-including both a behavioural and cognitive form-in predicting OCD symptoms.

DESIGN

Cross-sectional data were collected online from community-based adult participants.

METHODS

Participants (N = 673) completed a battery of self-report measures of OCD symptom severity, intolerance of uncertainty, and emotion-related impulsivity.

RESULTS

The behavioural form of emotion-related impulsivity positively moderated the relationship between intolerance of uncertainty and OCD symptoms. Elevated levels of both factors predicted the most severe symptoms, particularly checking, washing, and obsessing. This interaction effect was not found for the cognitive form of emotion-related impulsivity, which still emerged as a unique predictor of OCD symptom severity, specifically obsessing symptoms.

CONCLUSIONS

Current findings furthered the understanding of the link between intolerance of uncertainty and OCD symptoms by highlighting the role of emotion-related impulsivity. When uncertainty triggers distress in individuals with high intolerance of uncertainty, the urge to behaviourally alleviate this distress could promote the use of maladaptive obsessions and compulsions, leading to greater OCD symptoms. Results also indicated the potentially differential effects from the behavioural versus cognitive forms of emotion-related impulsivity on different symptom domains, and the mechanistic link here is worthy of further investigation.

Patient adherence as a predictor of acute and long-term outcomes in concentrated exposure treatment for difficult-to-treat obsessive-compulsive disorder

BACKGROUND

Exposure and response prevention (ERP) is considered the first-line psychotherapy for obsessive-compulsive disorder (OCD). Substantial research supports the effectiveness of ERP, yet a notable portion of patients do not fully respond while others experience relapse. Understanding poor outcomes such as these necessitates further research. This study investigated the role of patient adherence to ERP tasks in concentrated exposure treatment (cET) in a sample who had previously not responded to treatment or relapsed.

METHOD

The present study included 163 adults with difficult-to-treat OCD. All patients received cET delivered during four consecutive days. Patients' treatment adherence was assessed using the Patient EX/RP Adherence Scale (PEAS-P) after the second and third day of treatment. OCD severity was evaluated at post-treatment, 3-month follow-up, and 1-year follow-up by independent evaluators.

RESULTS

PEAS-P scores during concentrated treatment were associated with OCD-severity at post-treatment, 3-month follow-up, and 1-year follow-up. Moreover, PEAS-P scores predicted 12-month OCD severity adjusting for relevant covariates. Adherence also predicted work- and social functioning at 1-year follow-up.

CONCLUSIONS

These results indicate that ERP adherence during the brief period of cET robustly relates to improvement in OCD symptoms and functioning in both the short and long term. Assessing adherence might identify patients at risk of poor outcomes, while improving adherence may enhance ERP for treatment resistant patients.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02656342.

Functional impairment in a Spanish Sample of Children and Adolescents with Obsessive-Compulsive Disorder

The Child Obsessive-Compulsive Impact Scale (COIS-R) is a parent- and self-report measure of the impairment related to Obsessive-Compulsive Disorder (OCD) symptoms. Previous research has demonstrated the reliability and validity of the original version of the COIS-R; to date, however, the scale has not been validated for use in Spanish samples of pediatric OCD. The present study aimed to assess the psychometric properties of this in a clinical sample of pediatric OCD (n = 91). Analyses of internal consistency, convergent and divergent validity were conducted. For both the COIS-R report scales estimates similar to those in the original instrument were obtained for internal consistency, test-retest reliability, and convergent validity. Thus, the Spanish version of the COIS-R seems to retain sound psychometric properties of its original version; it appears to be a reliable instrument for the assessment of obsessive-compulsive impairment and the effects of treatment, and can be used in other cultural contexts.

Depressive symptoms during deep transcranial magnetic stimulation or sham treatment for obsessive-compulsive disorder

BACKGROUND

Evidence suggests that depressive symptoms tend to improve concurrently with obsessive-compulsive disorder (OCD) symptoms during cognitive behavioral therapy (CBT), despite depression not being the primary target of intervention. Studies examining the temporal or mediational relationships of OCD and depressive symptoms have indicated a bidirectional relationship, as prior levels of OCD symptoms influenced subsequent levels of depression, and vice versa. Deep transcranial magnetic stimulation (dTMS) has recently emerged as a treatment option for OCD. Whether dTMS affects depression symptoms similarly to CBT remains to be examined.

METHODS

The current study employed a random intercept cross-lagged panel model (RI-CLPM) to examine the relationship of OCD and depression symptoms in 94 treatment refractory patients, undergoing dTMS or sham treatment.

RESULTS

Both OCD and depression symptoms improved significantly. However, a stable, cross-lagged relationship between the variables was not supported. Changes in one symptom domain could not be used to predict the other.

LIMITATIONS

The present study was conducted in a treatment refractory population, meaning the present findings may not generalize to treatment naïve patients or those with less severe OCD symptoms. It is unclear whether the study was sufficiently powered to detect the effects of interest, and this concern also meant that examining the dTMS and sham groups independently was not feasible.

CONCLUSIONS

When treating OCD with dTMS, depression symptoms appear likely to diminish but should be monitored throughout, and additional interventions applied if needed.

The relationship between obsessive-compulsive disorder symptom subtypes and social adjustment

Background

Although it has been widely established that poor social functioning is a characteristic of obsessive-compulsive disorder (OCD), little research has examined the relationship between OCD symptom subtypes and domains of social functioning. Thus, the present study sought to examine the specific ways in which impairment in social adjustment occurs in each symptom subtype of OCD.

Methods

A total of 325 adult participants with a primary diagnosis of OCD were included in the study. Hierarchical linear regressions were used to compare the extent to which OCD symptom subtypes predicted social adjustment domains after controlling for OCD and depression severity.

Results

Hoarding was shown to be significantly associated with work functioning. Whereas both contamination and symmetry subtypes were significantly associated with social functioning, only the contamination subtype was associated with functioning within the family unit. The symptom subtypes of doubt and taboo thoughts were not significantly associated with any domains of social adjustment.

Conclusion

Consistent with previous research, our results suggest a differential impact of OCD symptom subtypes on social adjustment. They offer important implications for the specific domains to target in treatment for different symptom subtypes.

Sexual Orientation Intrusive Thoughts and Well-Being: The Mediating Role of Psychological Inflexibility

Sexual orientation intrusive thoughts are a debilitating form of obsessive-compulsive disorder. The present study aimed to elucidate how psychological inflexibility and dysfunctional beliefs may impact the relationships of sexual orientation intrusive thoughts and obsessive-compulsive (OC) symptoms with well-being. A total of 181 undergraduate students completed measures of sexual orientation intrusive thoughts, OC symptoms, psychological inflexibility, dysfunctional beliefs, and well-being. Results indicated positive correlations between psychological inflexibility, sexual orientation intrusive thoughts, dysfunctional beliefs, and OC symptoms, along with negative correlations between well-being and sexual orientation intrusive thoughts, OC symptoms, dysfunctional beliefs, and psychological inflexibility. Psychological inflexibility acted as a mediator between sexual orientation intrusive thoughts and well-being and between OC symptoms and well-being. Dysfunctional beliefs were not a significant mediator. These results suggest that psychological inflexibility may partially explain the association between OC symptoms and well-being, pointing toward the need for future research on the impact of psychological inflexibility on well-being in the context of OC symptoms.

Afraid to go out: Poor quality of life with phobic anxiety in a large cross-sectional adult epilepsy center sample

PURPOSE

People with epilepsy (PWE) have unmet healthcare needs, especially in the context of mental health. Although the current literature has established increased incidence of anxiety and depression in PWE and their contribution to poor quality of life, little is known regarding the presence and impact of specific phobia and agoraphobia. Our aim was to assess factors associated with high phobic/agoraphobic symptoms in a large, single tertiary epilepsy center sample, and to assess their impact on quality of life.

METHODS

In a diverse sample of 420 adults with epilepsy, cross-sectional association of demographic, epilepsy and cognitive factors with high phobic symptoms were assessed using multiple logistic regression. Symptoms were measured with the SCL-90R validated self-report subscale (T-score ≥ 60 considered high phobic symptom group). Multiple logistic regression modeling was used to assess for independent association of demographic and clinical variables with presence of high phobic symptoms, and multiple linear regression modeling was used to evaluate for independent cross-sectional associations with epilepsy-specific quality of life (QOLIE-89).

RESULTS

Lower education (adjusted OR 3.38), non-White race/ethnicity (adjusted OR 2.34), and generalized anxiety symptoms (adjusted OR 1.91) were independently associated with high phobic/agoraphobic symptoms, all p < 0.005. Phobic/agoraphobic symptoms were independently associated with poor quality of life as were depression symptoms, older age, and non-White race/ethnicity. Generalized anxiety did not demonstrate a significant independent association with quality of life in the multivariable model.

CONCLUSION

In this study sample, phobic/agoraphobic symptoms were independently associated with poor quality of life. Clinicians should consider using more global symptom screening instruments with particular attention to susceptible populations, as these impactful symptoms may be overlooked using generalized-anxiety focused screening paradigms.

A double blind randomized clinical trial of the effectiveness of low frequency rTMS over right DLPFC or OFC for treatment of obsessive-compulsive disorder

We compared the effectiveness of low frequency repetitive transcranial magnetic stimulation over right dorsolateral prefrontal cortex (DLPFC), right orbitofrontal cortex (OFC) and sham for treatment of obsessive-compulsive disorder (OCD) and sought to determine possible predictors of effective treatment. Sixty OCD patients participated and were randomly allocated to one of the 3 treatment groups. Treatment was administered daily for 10 days. Assessments were made at the beginning and end of therapy as well as three months later using the Yale-Brown obsessive compulsive scale (Y-BOCS), Hamilton Anxiety Rating Scale (HAM-A), Beck Depression Inventory (BDI), and Clinical Global Impression - Severity scale (CGI-S). There were no significant demographic or clinical differences between the groups at baseline. One-way repeated measures ANOVA showed that participants in all 3 groups improved their scores on all rating scales following treatment. A two-way repeated measures ANOVA revealed a significant time and group interaction due to the fact that both active treatment groups outperformed the sham group, although there was no significant difference between the two. Percent improvement had significant negative correlations with the following factors: duration of illness, baseline Y-BOCS, HAM-A, and BDI. We conclude that rTMS over either right DLPFC or OFC has a therapeutic effect on OCD symptoms. Patients with lower Y-BOCS and fewer comorbidities responded best to rTMS.

Co-occurring depression and obsessive-compulsive disorder: A dimensional network approach

BACKGROUND

Depressive and obsessive-compulsive (OCD) symptoms often co-occur and a number of possible explanations for this co-occurrence have been explored, including shared biological and psychosocial risk factors. Network approaches have offered a novel hypothesis for the link between depression and OCD: functional inter-relationships across the symptoms of these conditions. The few network studies in this area have relied largely on item, rather than process-level constructs, and have not examined relationships dimensionally.

METHODS

Network analytic methods were applied to data from 463 treatment-seeking adults with OCD. Patients completed self-report measures of OCD and depression. Factor analysis was used to derive processes (i.e., nodes) to include in the network. Networks were computed, and centrality, bridge, and stability statistics examined.

RESULTS

Networks showed positive relations among specific OCD and depressive symptoms. Obsessions (particularly repugnant thoughts), negative affectivity, and cognitive-somatic changes (e.g., difficulty concentrating) were central to the network. Unique relations were observed between symmetry OCD symptoms and cognitive-somatic changes. No direct link between harm-related OCD symptoms and depression was observed.

CONCLUSIONS

Our results bring together prior findings, suggesting that both negative affective and psychomotor changes are important to consider in examining the relationship between OCD and depression. Increased consideration of heterogeneity in the content of OCD symptoms is key to improving clinical conceptualizations, particularly when considering the co-occurrence of OCD with other disorders.

Statistical predictors of psychosocial impairment in body-focused repetitive behaviors

BACKGROUND

Skin picking disorder and trichotillomania, also characterized as body-focused repetitive behaviors (BFRBs), often lead to functional impairment. Some people with BFRBs, however, report little if any psychosocial dysfunction. There has been limited research as to which clinical aspects of BFRBs are associated with varying degrees of functional impairment.

METHODS

Adults (n = 98), ages 18 to 65 with a current diagnosis of trichotillomania (n = 37), skin picking disorder (n = 32), trichotillomania plus skin picking disorder (n = 10), and controls (n = 19) were enrolled. Partial least squares regression (PLS) was used to identify variables associated with impairment on the Sheehan Disability Scale.

RESULTS

PLS identified an optimal model accounting for 45.8% of variation in disability. Disability was significantly related to (in order of descending coefficient size): severity of picking, perceived stress, comorbid disorders (specifically, anxiety disorders / obsessive-compulsive disorder), trait impulsivity, family history of alcohol use disorder, atypical pulling/picking sites, and older age.

CONCLUSIONS

At present mental disorders are viewed as unitary entities; however, the extent of impairment varies markedly across patients with BFRBs. These data suggest that whereas symptom nature/severity is important in determining impairment, so too are other variables commonly unmeasured in clinical practice. Outcomes for patients may thus be maximized by rigorously addressing comorbid disorders; as well as integrating components designed to enhance top-down control and stress management. Interestingly, focused picking and emotional pulling were linked to worse disability, hinting at some differences between the two types of BFRBs, in terms of determinants of impairment.

Quality of life in pediatric patients with obsessive-compulsive disorder during and 3 years after stepped-care treatment

The present study aimed to investigate the long-term quality of life (QoL) in a large sample of pediatric obsessive-compulsive disorder (OCD) patients. The study included 220 pediatric OCD patients from the Nordic Long-term OCD Treatment Study (NordLOTS) who were evaluated at seven time points before, during, and after stepped-care treatment over a 3-year follow-up period. Data from three symptom severity trajectory classes formed the basis of the QoL evaluation: acute (n = 127, N = 147), slow (n = 46, N = 63), and limited responders (n = 47, N = 59). Patients' QoL was assessed using parent and child ratings of the revised Questionnaire for Measuring Health-related Quality of Life in Children and Adolescents (KINDL-R). QoL was analyzed by trajectory class using a random mixed effects model. The association between pre-treatment factors and long-term QoL was investigated across classes in a multivariate model. Three years after treatment, the acute responder class had reached QoL levels from a general population, whereas the limited responder class had not. The slow responder class reached norm levels for the child-rated QoL only. Higher levels of co-occurring externalizing symptoms before treatment were associated with lower parent-rated QoL during follow-up, while adolescence and higher levels of co-occurring internalizing symptoms were associated with lower child-rated QoL during follow-up. For some patients, residual OCD symptoms in the years after treatment, even at levels below assumed clinical significance, are associated with compromised QoL. Co-occurring symptoms could be part of the explanation. Assessing QoL after OCD treatment, beyond the clinician-rated symptom severity, could detect patients in need of further treatment and/or assessment. Trial registry: Nordic Long-term Obsessive-Compulsive Disorder (OCD) Treatment Study; www.controlled-trials.com ; ISRCTN66385119.

An examination of obsessive-compulsive symptom domains, depression, and quality of life within an online survey sample

Obsessive-compulsive disorder (OCD) is a heterogeneous and highly impairing disorder that is frequently comorbid with other conditions. Participants in this study were 212 individuals recruited through Mechanical Turk who filled out validated measures of obsessive-compulsive symptoms, quality of life (QoL), generalized anxiety, and depressive symptoms. Analyses examined the influences of each symptom variable on QoL and the mediating role of depression as an indirect link between unacceptable thoughts (UT) and QoL. Depressive symptoms had a significant negative relationship with multiple domains of functioning. Generalized anxiety was not significant. Higher endorsement of UT symptoms was related to lower physical, emotional, and social QoL. Depression partially mediated the relationship between UT symptoms and physical, emotional, and social health. Depressive symptoms are important to consider in clinical work surrounding OCD. The significant associations between UT symptoms and QoL in a nonclinical population illustrate a relevant area for future intervention, public awareness, and education.

Psychometric Evaluation of the Pediatric Quality of Life Enjoyment and Satisfaction Questionnaire in a General Youth Population

Pediatric Quality of Life Enjoyment and Satisfaction Questionnaire is a brief 15-item self-report measure of quality of life and life satisfaction originally developed for clinical populations (6 to 17 years old). The current paper examines the initial factor structure proposed by the developers and underlying psychometric properties of the measure in a non-clinical population of teens. A cross-sectional adolescent sample (N = 3222) completed self-report measures as part of mental health promotion program. A confirmatory factor analysis was conducted with construct validity analyses. The original factor structure was replicated with strong internal consistency (Cronbach α = .912). Strong construct validity (e.g. resilience, well-being, depression, and anxiety) was found. Minimal differences were found based on gender, race, and ethnicity. PQ-LES-Q has strong, replicable psychometric properties, which makes it a generally reliable and valid assessment tool to evaluate the quality of life and life satisfaction in adolescents.

Predictors of suicide attempt in patients with obsessive-compulsive disorder: an exploratory study with machine learning analysis

BACKGROUND

Patients with obsessive-compulsive disorder (OCD) are at increased risk for suicide attempt (SA) compared to the general population. However, the significant risk factors for SA in this population remains unclear - whether these factors are associated with the disorder itself or related to extrinsic factors, such as comorbidities and sociodemographic variables. This study aimed to identify predictors of SA in OCD patients using a machine learning algorithm.

METHODS

A total of 959 outpatients with OCD were included. An elastic net model was performed to recognize the predictors of SA among OCD patients, using clinical and sociodemographic variables.

RESULTS

The prevalence of SA in our sample was 10.8%. Relevant predictors of SA founded by the elastic net algorithm were the following: previous suicide planning, previous suicide thoughts, lifetime depressive episode, and intermittent explosive disorder. Our elastic net model had a good performance and found an area under the curve of 0.95.

CONCLUSIONS

This is the first study to evaluate risk factors for SA among OCD patients using machine learning algorithms. Our results demonstrate an accurate risk algorithm can be created using clinical and sociodemographic variables. All aspects of suicidal phenomena need to be carefully investigated by clinicians in every evaluation of OCD patients. Particular attention should be given to comorbidity with depressive symptoms.

Examining depression symptoms within OCD: the role of experiential avoidance

BACKGROUND

Obsessive compulsive disorder (OCD) and depression commonly co-occur. Past research has evaluated underlying mechanisms of depression in the context of other diagnoses, but few to no studies have done this within OCD.

AIMS

This study examines the relationships between distress tolerance (DT), experiential avoidance (EA), depression, and OCD symptom severity across intensive/residential treatment (IRT) for OCD. It was hypothesized that all variables would be significantly moderately related and EA would emerge as a potential contributing factor to change in depression and OCD symptoms across IRT for OCD.

METHOD

The sample included 311 participants with a primary diagnosis of OCD seeking IRT. Correlations were performed between all variables at both admission and discharge. A two-step hierarchical regression with change in OCD symptoms and change in DT in the first block and change in EA in the second block examined if change in EA explained change in depression above and beyond change in OCD and DT ability.

RESULTS

At both admission and discharge, higher EA, lower DT, and higher OCD symptom severity were significantly associated with more depressive symptoms. Change in EA explained a significant amount of variance in change in depression above and beyond change in OCD symptom severity and change in DT.

CONCLUSIONS

This study expands past results within an OCD sample, emphasizing EA as an important treatment target in OCD. Future studies could utilize samples from other treatment contexts, use a measure of EA specific to OCD, and utilize a longitudinal model that takes temporal precedence into account.

Obsessive-Compulsive Disorders

PURPOSE OF REVIEW

This article describes the phenomenology and clinical presentation of obsessive-compulsive disorder (OCD), a common but underdiagnosed psychiatric disorder. Guidance for effectively identifying obsessive-compulsive symptoms is provided, and treatment options, including psychotherapy, pharmacologic management, and neuromodulation approaches for treatment-resistant OCD, are discussed.

RECENT FINDINGS

OCD affects 2% to 3% of adults worldwide and is associated with substantial individual disability and societal costs. Lack of recognition of common OCD symptom types, in addition to shame and fear of stigma on the part of patients, has created an average delay in diagnosis by almost 10 years and a delay in effective treatment (ie, a treatment gap) of nearly 2 years. Cognitive-behavioral therapy (CBT), specifically a form of CBT that includes a type of behavioral intervention called exposure and response prevention, remains the most effective form of treatment for OCD. If CBT is not effective or not available, pharmacologic treatment with selective serotonin reuptake inhibitors (SSRIs) or clomipramine, a nonselective serotonin reuptake inhibitor, can also be of benefit. Neuromodulation approaches such as deep brain stimulation and transcranial magnetic stimulation are rapidly emerging as effective treatments for OCD, particularly for patients who have not experienced an adequate response to psychotherapy or pharmacologic management.

SUMMARY

OCD affects more than one in every 50 adults in the United States but is recognized and adequately treated in fewer than half of those affected. Early intervention and appropriate treatment can substantially reduce OCD symptom severity, improve quality of life, and minimize the functional disability associated with this chronic and often debilitating illness.

Bidirectional Behavioral Selection in Mice: A Novel Pre-clinical Approach to Examining Compulsivity

Obsessive-compulsive disorder (OCD) and related disorders (OCRD) is one of the most prevalent neuropsychiatric disorders with no definitive etiology. The pathophysiological attributes of OCD are driven by a multitude of factors that involve polygenic mechanisms, gender, neurochemistry, physiological status, environmental exposures and complex interactions among these factors. Such complex intertwining of contributing factors imparts clinical heterogeneity to the disorder making it challenging for therapeutic intervention. Mouse strains selected for excessive levels of nest- building behavior exhibit a spontaneous, stable and predictable compulsive-like behavioral phenotype. These compulsive-like mice exhibit heterogeneity in expression of compulsive-like and other adjunct behaviors that might serve as a valuable animal equivalent for examining the interactions of genetics, sex and environmental factors in influencing the pathophysiology of OCD. The current review summarizes the existing findings on the compulsive-like mice that bolster their face, construct and predictive validity for studying various dimensions of compulsive and associated behaviors often reported in clinical OCD and OCRD.

Double blind randomized controlled trial of deep brain stimulation for obsessive-compulsive disorder: Clinical trial design

Obsessive-compulsive disorder (OCD), a leading cause of disability, affects ~1–2% of the population, and can be distressing and disabling. About 1/3 of individuals demonstrate poor responsiveness to conventional treatments. A small proportion of these individuals may be deep brain stimulation (DBS) candidates. Candidacy is assessed through a multidisciplinary process including assessment of illness severity, chronicity, and functional impact. Optimization failure, despite multiple treatments, is critical during screening. Few patients nationwide are eligible for OCD DBS and thus a multi-center approach was necessary to obtain adequate sample size. The study was conducted over a six-year period and was a NIH-funded, eight-center sham-controlled trial of DBS targeting the ventral capsule/ventral striatum (VC/VS) region. There were 269 individuals who initially contacted the sites, in order to achieve 27 participants enrolled. Study enrollment required extensive review for eligibility, which was overseen by an independent advisory board. Disabling OCD had to be persistent for ≥5 years despite exhaustive medication and behavioral treatment. The final cohort was derived from a detailed consent process that included consent monitoring. Mean illness duration was 27.2 years. OCD symptom subtypes and psychiatric comorbidities varied, but all had severe disability with impaired quality of life and functioning. Participants were randomized to receive sham or active DBS for three months. Following this period, all participants received active DBS. Treatment assignment was masked to participants and raters and assessments were blinded. The final sample was consistent in demographic characteristics and clinical features when compared to other contemporary published prospective studies of OCD DBS. We report the clinical trial design, methods, and general demographics of this OCD DBS sample.

Fathers' Experience of Perinatal Obsessive-Compulsive Symptoms: A Systematic Literature Review

Perinatal Obsessive-Compulsive Disorder (pOCD) refers to the onset/exacerbation of Obsessive-Compulsive Disorder (OCD) during the perinatal period. This disorder has been studied in mothers, with limited research conducted on fathers. The aim of the current study was to conduct the first systematic review of research investigating the experience of pOCD in fathers. A systematic review was conducted via electronic searches of Scopus, ProQuest, APA PsychNet, PubMed, and EBSCOhost. There were 523 articles identified and screened for eligibility, resulting in six eligible studies included in the final review. All studies reported the presence of subclinical obsessive-compulsive symptoms in fathers during the perinatal period, with the prevalence comparable to mothers. Compared to mothers, however, fathers were found to report less intrusion-related distress. Two studies reported a correlation between dysfunctional beliefs, negative appraisal of intrusions, and pOCD symptoms. Common categories of obsessive thoughts and compulsions experienced by fathers were also identified. Fathers appear susceptible to pOCD, which is consistent with the Cognitive-Behavioral Theory of OCD. Future research is recommended, therefore, to investigate clinical prevalence and severity of pOCD in fathers, particularly relative to mothers, and further investigate the role of dysfunctional beliefs in the development of pOCD.

Family accommodation in Chinese individuals with obsessive-compulsive disorder

Family accommodation is a common, treatment-relevant construct related to obsessive-compulsive disorder (OCD) severity and treatment outcome. This initial study examined the nature, incidence, and clinical correlates of family accommodation in Chinese adults with OCD and their relative or person in a close relationship. One hundred four outpatients diagnosed with OCD completed self-report measures of obsessive-compulsive, anxiety, and depression symptoms. Additionally, the individuals with OCD and a relative completed a measure of family accommodation and impairment. Patient-reports of family accommodation were significantly correlated with OCD symptomology and severity. A multiple linear regression indicated that OCD symptomology was a significant predictor of family accommodation, but anxiety, stress, and depression were not. In addition, the current Chinese sample demonstrated greater levels of family accommodation than previous English-speaking samples. Potential explanations and implications of the high levels of reported family accommodation are discussed. Family accommodation could play a significant role in OCD development and/or maintenance in China. Future research considerations are discussed.

Treatment Adherence as Predictor of Outcome in Concentrated Exposure Treatment for Obsessive-Compulsive Disorder

Background: The treatment of choice for obsessive-compulsive disorder (OCD) is exposure and response prevention (EX/RP). Previous studies have demonstrated that treatment adherence predicts treatment outcome for patients with OCD, but there is little knowledge on its role in concentrated exposure treatment for OCD. Method: In the present study, 42 patients received EX/RP treatment using the Bergen 4-day format. Adherence was measured with the Exposure and Response Prevention Adherence Scale (PEAS, rated both by patients and therapists) after the second and third day. Treatment outcome (symptoms of OCD, depression, anxiety, work- and social functioning, and well-being) was assessed at 3-month follow-up. Results: At follow-up, 71.4% were in remission. High adherence was reported (mean score of 6 on a 1-7 scale). The combination of patient- and therapist rated adherence was significantly associated with treatment outcome whilst controlling for age, sex, and pre-treatment scores. Patients with higher degree of adherence reported less symptoms, higher functioning, and more well-being at follow-up. Conclusions: The results of the present study indicated that adherence in concentrated exposure treatment is significantly associated with a wide range of treatment outcomes for OCD.

Effects and side effects of a transdiagnostic bias modification intervention in a mixed sample with obsessive-compulsive and/or depressive symptoms-a randomized controlled trial

Obsessive-compulsive disorder (OCD) and major depression disorder (MDD) are underdiagnosed and undertreated mental disorders. Prior studies have verified the efficacy of the self-help manual My Metacognitive Training (myMCT) for patients with primary OCD. As depression and OCD share a number of (meta)cognitive biases and dysfunctional coping strategies, we examined the efficacy of myMCT in a mixed patient sample with OCD and/or depression. A total of 80 Italian-speaking individuals with symptoms of OCD and/or depression were randomized to either myMCT or to a waitlist control group (both groups had access to care as usual during the intervention). Post-assessment was carried out 6 weeks after inclusion. Scores on the Beck Depression Inventory-II scale (BDI-II) served as the primary outcome. Adverse effects were assessed with a newly devised self-report scale. Participants in the myMCT condition showed significant symptom improvement on the BDI-II scale at a medium to large effect size compared to the control group (using intention-to-treat and per protocol analyses). The intention-to-treat analyses yielded significant positive effects on the PHQ-9 scores and psychological as well as environmental well-being in favor of myMCT; for the OCI-R total score, group differences bordered significance in favor of the myMCT. The most prevalent adverse effects were feeling pressured by the suggested exercises or feeling bad due to not performing the exercises correctly. Our results indicate that the myMCT manual represents an effective program for patients with OCD as well as those with depressive symptoms in an Italian-speaking population. Adverse events due to unguided self-help deserve more attention in the future.

The suicidality continuum in a large sample of obsessive–compulsive disorder (OCD) patients

Background

Obsessive–compulsive disorder (OCD) has a chronic course leading to huge impact in the patient’s functioning. Suicidal thoughts and attempts are much more frequent in OCD subjects than once thought before.

Aim

To empirically investigate whether the suicidal phenomena could be analyzed as a suicidality severity continuum and its association with obsessive–compulsive (OC) symptom dimensions and quality of life (QoL), in a large OCD sample.

Methods

Cross-sectional study with 548 patients diagnosed with OCD according to the DSM-IV criteria, interviewed in the Brazilian OCD Consortium (C-TOC) sites. Patients were evaluated by OCD experts using standardized instruments including: Yale-Brown Obsessive–Compulsive Scale (YBOCS); Dimensional Yale-Brown Obsessive–Compulsive Scale (DYBOCS); Beck Depression and Anxiety Inventories; Structured Clinical Interview for DSM-IV (SCID); and the SF-36 QoL Health Survey.

Results

There were extremely high correlations between all the suicidal phenomena. OCD patients with suicidality had significantly lower QoL, higher severity in the “sexual/religious”, “aggression” and “symmetry/ordering” OC symptom dimensions, higher BDI and BA scores and a higher frequency of suicide attempts in a family member. In the regression analysis, the factors that most impacted suicidality were the sexual dimension severity, the SF-36 QoL Mental Health domain, the severity of depressive symptoms and a relative with an attempted suicide history.

Conclusions

Suicidality could be analyzed as a severity continuum and patients should be carefully monitored since they present with suicidal ideation. Lower QoL scores, higher scores on the sexual dimension and a family history of suicide attempts should be considered as risk factors for suicidality among OCD patients.

Changes in the daily life experience of patients with obsessive-compulsive disorder following mindfulness-based cognitive therapy: Looking beyond symptom reduction using ecological momentary assessment

The current study examines changes in daily life experiences following mindfulness-based cognitive therapy (MBCT) in a sample of 38 patients with obsessive-compulsive disorder (OCD) and residual symptoms following cognitive behavioral therapy (CBT). Participants were randomized to either an MBCT group (n = 17), or to a psychoeducational group (OCD-EP; n = 21) as an active control condition. Both groups underwent ecological momentary assessment (EMA) six times a day for a period of six consecutive days pre- and posttreatment. Contrary to hypotheses, MBCT participation did not, when compared to OCD-EP, result in significant changes of positive affect, negative affect, acceptance of momentary emotions, or distress associated with obsessive-compulsive (OC) symptoms. In fact, insight into the unreasonableness of OC symptoms improved significantly more in the OCD-EP group compared to MBCT. However, in the MBCT group, the presence of momentary OC symptoms at post assessment predicted increased insight, which indicates an improved ability to detach from OC symptoms in the moments in which they occur. All in all, however, results do not indicate favorable changes in everyday life experiences of OCD patients following MBCT. Owing to the modest sample size, results must be considered preliminary. Implications and directions for future research are discussed.

A Psycho-Behavioral Perspective on Modelling Obsessive-Compulsive Disorder (OCD) in Animals: The Role of Context

Obsessive-compulsive disorder is a heterogeneous and debilitating condition, characterized by intrusive thoughts and compulsive repetition. Animal models of OCD are important tools that have the potential to contribute significantly to our understanding of the condition. Although there is consensus that pre-clinical models are valuable in elucidating the underlying neurobiology in psychiatric disorders, the current paper attempts to prompt ideas on how interpretation of animal behavior can be expanded upon to more effectively converge with the human disorder. Successful outcomes in psychopharmacology involve rational design and synthesis of novel compounds and their testing in well-designed animal models. As part of a special journal issue on OCD, this paper will 1) review the psychobehavioral aspects of OCD that are of importance on how the above ideas can be articulated, 2) briefly elaborate on general issues that are important for the development of animal models of OCD, with a particular focus on the role and importance of context, 3) propose why translational progress may often be less than ideal, 4) highlight some of the significant contributions afforded by animal models to advance understanding, and 5) conclude by identifying novel behavioral constructs for future investigations that may contribute to the face, predictive and construct validity of OCD animal models. We base these targets on an integrative approach to face and construct validity, and note that the issue of treatment-resistance in the clinical context should receive attention in current animal models of OCD.

Predictors of acute outcomes for intensive residential treatment of obsessive-compulsive disorder

For those who suffer with chronic and disruptive obsessive-compulsive disorder (OCD), who have not been sufficiently helped by outpatient treatments or medications, intensive residential treatment (IRT) is often the next best treatment option. To date, research of the predictors of treatment outcome in IRT for OCD are mixed and sometimes contradictory. Additionally, although comorbidity is common for patients in this setting, the inclusion of comorbidity as a potential predictor of outcome has been mostly lacking in research to date. The current study aimed to address these issues by utilizing optimal indices of treatment outcomes, while incorporating comorbidity into our analyses, in order to identify the predictors of treatment outcomes in the IRT for OCD setting. To this end, we analysed outcome data from 379 patients receiving IRT for OCD at the Rogers Memorial OCD Center between August 2012, and December 2017. Results indicated that the most important predictor of treatment outcome was obsession severity at admission. Specifically, higher obsession severity at admission predicted poorer treatment outcomes at discharge. Clinical implications and suggestions for future research were discussed in the manuscript.

Quality of life in children and adolescents with obsessive-compulsive disorder: The Pediatric Quality of Life Enjoyment and Satisfaction Questionnaire (PQ-LES-Q)

The current study examined quality of life (QOL) and its clinical correlates among 225 intensive treatment-seeking children and adolescents with obsessive-compulsive disorder (OCD) using the Pediatric Quality of Life Enjoyment and Satisfaction Questionnaire (PQ-LES-Q). Youth completed the PQ-LES-Q along with self-report measures assessing functional impairment, anxiety sensitivity, OCD symptoms, nonspecific anxiety, depression, and social anxiety. Parents completed measures on their child's anxiety, the presence of inattention/hyperactivity, depression, functional impairment, and frequency of family accommodation of symptoms. Contrary to expectation, child-reported OCD symptoms did not significantly predict QOL; however, lower overall QOL was strongly associated with the presence of comorbid major depressive disorder (g=3D -0.76) and slightly related to comorbid social phobia (g=3D -0.36). These results suggest that assessing and addressing comorbid conditions in the treatment of youth with OCD is an important component of intensive treatment.

Clinical predictors of quality of life in a large sample of adult obsessive-compulsive disorder outpatients

BACKGROUND

OCD causes impairment in different areas of the patients' quality of life (QoL), such as sociability, family relationships, and occupational performance. The literature has emphasized the relevance of assessing QoL as a critical outcome in mental health studies.

AIMS

The aim of this study was to investigate sociodemographic and clinical predictors of QoL, including treatment response, in a large sample of OCD subjects.

PROCEDURES

575 adult OCD outpatients were interviewed as part of the Brazilian OCD Consortium (CTOC). A smaller number of subjects (N = 143) participated on a clinical trial conducted by one of the CTOC sites.

RESULTS

OCD patients were more impaired in their QoL when compared to the Brazilian normative data. Obsessive-compulsive symptoms (OCS) severity had significant correlations with all Medical Outcome Short-Form questionnaire (SF-36) domains. Different OCS dimensions had specific correlations with each SF-36 domain. OCS, depression and anxiety severity significantly increased the impairment risk for the SF-36 domains. Suicidality increased the relative risks for impairment in the Role-Functioning and the Vitality domains by 51% and 17%, respectively. There was a significant improvement in some SF-36 dimensions after treatment.

CONCLUSIONS

QoL domains are highly compromised in OCD patients. Each SF-36 domain had distinct associations with sociodemographic and clinical variables, including OCS dimensions, suicidality and treatment response. These findings emphasize the OCD heterogeneity and the need for including QoL assessment in clinical practice and research studies.

New Directions in the Cognitive-Behavioral Treatment of OCD: Theory, Research, and Practice

The beneficial effects of cognitive-behavioral interventions (particularly exposure and response prevention) for OCD are among the most consistent research findings in the mental health literature. Nevertheless, even after an adequate trial, many individuals experience residual symptoms, and others never receive adequate treatment due to limited access. These and other issues have prompted clinicians and researchers to search for ways to improve the conceptual and practical aspects of existing treatment approaches, as well as look for augmentation strategies. In the present article, we review a number of recent developments and new directions in the psychological treatment of OCD, including (a) the application of inhibitory learning approaches to exposure therapy, (b) the development of acceptance-based approaches, (c) involvement of caregivers (partners and parents) in treatment, (d) pharmacological cognitive enhancement of exposure therapy, and (e) the use of technology to disseminate effective treatment. We focus on both the conceptual/scientific and practical aspects of these topics so that clinicians and researchers alike can assess their relative merits and disadvantages.

Responsibility beliefs and persecutory delusions

Recent research implicates cognitive processes traditionally linked to anxiety disorders in the maintenance of paranoia. Responsibility beliefs have traditionally been associated with OCD, and recent research suggests they may be transdiagnostic. The present study reports the first data on responsibility beliefs in individuals with persecutory delusions. 30 people with persecutory delusions completed measures of psychotic symptoms and responsibility beliefs. Participants were also asked to identify who they held responsible for their persecution. Quantitative data on responsibility beliefs were compared with 29 matched non-clinical control participants, and with published data from patients with OCD and anxiety disorders. People with persecutory delusions identified a number of different entities responsible for harm. The persecutory delusions group had higher responsibility beliefs than those with OCD, anxiety disorders and nonclinical controls. The results suggest that responsibility beliefs are a facet of the phenomenology of persecutory beliefs. Cognitive-behavioural therapy for psychosis might usefully draw from OCD interventions and focus on responsibility beliefs, perhaps especially in Bad Me paranoia.

Dissecting the Yale-Brown Obsessive-Compulsive Scale severity scale to understand the routes for symptomatic improvement in obsessive-compulsive disorder

We aimed to investigate which items of the Yale-Brown Obsessive-Compulsive Severity Scale best discriminate the reduction in total scores in obsessive-compulsive disorder patients after 4 and 12 weeks of pharmacological treatment. Data from 112 obsessive-compulsive disorder patients who received fluoxetine (⩽80 mg/day) for 12 weeks were included. Improvement indices were built for each Yale-Brown Obsessive-Compulsive Severity Scale item at two timeframes: from baseline to week 4 and from baseline to week 12. Indices for each item were correlated with the total scores for obsessions and compulsions and then ranked by correlation coefficient. A correlation coefficient ⩾0.7 was used to identify items that contributed significantly to reducing obsessive-compulsive disorder severity. At week 4, the distress items reached the threshold of 0.7 for improvement on the obsession and compulsion subscales although, contrary to our expectations, there was greater improvement in the control items than in the distress items. At week 12, there was greater improvement in the time, interference, and control items than in the distress items. The use of fluoxetine led first to reductions in distress and increases in control over symptoms before affecting the time spent on, and interference from, obsessions and compulsions. Resistance did not correlate with overall improvement. Understanding the pathway of improvement with pharmacological treatment in obsessive-compulsive disorder may provide clues about how to optimize the effects of medication.

Eating disorder severity and functional impairment: moderating effects of illness duration in a clinical sample

PURPOSE

The aim was to examine duration of illness and body mass index as possible moderators of the relationship between eating disorder severity and functional impairment, as well as psychological distress as a possible mediator of this relationship.

METHODS

The study included 159 patients diagnosed with bulimia nervosa, binge eating disorder or eating disorder not otherwise specified. Regression analysis was applied to assess the effect of the hypothesized moderators and mediators. Eating disorder severity was measured with the Eating Disorder Examination Questionnaire, functional impairment was measured with the Sheehan Disability Scale, and psychological distress was measured with the Symptom Check List-90-R. Duration of illness and body mass index were assessed clinically.

RESULTS

Duration of illness significantly moderated the relationship between eating disorder severity and functional impairment; the relationship was strongest for patients with a shorter duration of illness. Psychological distress partly mediated the relationship between eating disorder severity and functional impairment. Duration of illness significantly moderated the relationship between psychological distress and functional impairment; the strongest relationship was seen for patients with a shorter duration of illness. Body mass index was not a significant moderator of the relationship between ED severity and functional impairment.

CONCLUSIONS

Overall, this study established a link between ED severity, psychological distress and functional impairment indicating that both eating disorder severity and psychological distress are more strongly related to impaired role functioning for patients with more recent onset of an eating disorder. More research in the complex relationship between ED severity and functional impairment is needed.

Register-based study of the incidence, comorbidities and demographics of obsessive-compulsive disorder in specialist healthcare

BACKGROUND

Incidence of obsessive-compulsive disorder (OCD) has been suspected to increase but nationwide epidemiological studies are limited. This study aims to examine sex-specific incidence time trends and characterize psychiatric and neurodevelopmental comorbidities and sociodemographic risk factors of OCD in specialist healthcare in Finland.

METHODS

A nationwide register-based study using data from four Finnish registers identified 3372 OCD cases and 13,372 matched controls (1:4). Cumulative incidence in subjects born between 1987 and 2001 was estimated at ages of 10, 15, 20 and 23 years. Conditional logistic regression was used to examine the sociodemographic factors.

RESULTS

The cumulative incidence of OCD was 0.4% by age 23. Incidence by age 15 among three cohorts increased from 12.4 to 23.7 /10000 live born males and 8.5 to 28.0 /10000 live born females. 73% of the sample had a comorbid condition. Males were significantly more comorbid with psychotic and developmental disorders; females were more comorbid with depressive and anxiety disorders (p <0.001). Higher maternal SES was associated with an increased risk of OCD (OR 1.4; 95% CI 1.1-1.6).

CONCLUSIONS

These findings suggest that incidence of treated OCD in specialist healthcare has increased. The reason may be increased awareness and rate of referrals but a true increase cannot be ruled out. Further research on risk factors of OCD is warranted.

“Winter Is Coming!”—Treatment of Obsessive-Compulsive Disorder Imagery After Viewing the Television Series Game of Thrones

This article presents the detailed case of a 27-year-old man who began to suffer from intrusive imagery after watching a brutal scene in the TV series Game of Thrones. The content of the intrusive imagery included images of people with enucleated eyes and was initially accompanied by anxiety about sharp objects. The patient’s mental distress was assessed by the Yale-Brown Obsessive Compulsive Scale and the Impact of Event Scale—Revised, and the patient was diagnosed with obsessive-compulsive disorder (OCD). Eye movement desensitization and reprocessing (EMDR) therapy was provided to treat related distressing memories and the intrusive imagery. As treatment progressed, more complex and layered aspects of the symptom presentation became evident, and EMDR was integrated with other treatments. These included psychodynamic psychotherapy to address his complicated relationship with his father, exposure and response prevention (ERP) therapy to reduce avoidance of sharp objects, and cognitive therapy (CT) for aggressive violent thoughts toward others. The article identifies the various clinical decision points and discusses theoretical conceptualizations and related factors. This clinical case report provides additional support for the body of knowledge on the relationship between traumatic events and imagery in OCD. Therefore, trauma-focused treatments, such as EMDR therapy, which concentrates specifically on those experiences, might be especially effective.

Adult obsessive-compulsive disorder and quality of life outcomes: A systematic review and meta-analysis

In the current literature, there are no meta-analyses assessing quality of life (QOL) in patients with obsessive-compulsive disorder (OCD). Knowledge of QOL domains mainly impaired in OCD could provide specific areas for intervention. The current meta-analysis assessed differences in global, work and social, family, and emotional QOL outcomes between patients with OCD and heathy controls. Age, gender and OCD severity were examined as moderators. Case-control studies were included if patients with primary OCD were compared with controls on QOL outcomes. Electronic databases (1966-October 2014) were searched. Thirteen case-control studies were included (n=26,015). Patients with OCD had significantly lower scores on QOL relative to controls, with moderate effect sizes on global QOL and large effect size on work and social, emotional and family QOL outcomes. Studies using higher percentages of female patients and patients with less severe OCD symptoms reported significantly lower QOL outcomes for patients with OCD than controls. Studies comparing patients with OCD and patients with other psychiatric disorders were not included. Treatments should address QOL in OCD, particularly emotional QOL. Additional strategies targeting QOL should be implemented for female patients with less severe OCD symptoms.

Further psychometric properties of the Yale-Brown Obsessive Compulsive Scale - Second Edition

The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) is a widely used clinician-rated measure for assessing obsessive-compulsive symptoms. Although numerous studies have supported its reliability and validity, improved phenomenological understanding of obsessive-compulsive disorder (OCD) suggests the need for modifications to item content, structure, and scoring. Consequently, the Yale-Brown Obsessive Compulsive Scale - Second Edition (Y-BOCS-II) was developed. While the Y-BOCS-II shows initial promise, minimal data exist in examining the psychometric properties of the Y-BOCS-II English version. In response, the Y-BOCS-II was administered to 61 adult patients with a principal diagnosis of obsessive-compulsive disorder. The internal consistency for the scores on the Obsession Severity (α=.83), Compulsion Severity (α=.75), and Total Severity (α=.86) scales were acceptable to good. The inter-rater reliability for the severity scale scores was excellent (ICC=.97-99) and the test-retest reliability was acceptable (r=.64-81). Strong convergent validity was observed between the Y-BOCS-II Total Severity scale and other measures of obsessive-compulsive symptom severity and related impairment. Good divergent validity was supported by non-significant correlations between the Total Severity score and measures of anxiety and impulsiveness, though a moderate correlation was observed with depressive symptoms. Collectively, the Y-BOCS-II generally possesses sound psychometric properties and appears to be a viable alternative to the original Y-BOCS.

Social behavior in deer mice as a novel interactive paradigm of relevance for obsessive-compulsive disorder (OCD)

Greater obsessive-compulsive (OC) symptom severity may be associated with poor social adjustment. Rather than possessing deficits in social skill per se, OCD patients may be more socially isolative in the presence of normal controls. We aimed to apply a novel social interaction challenge (SIC) to an established animal model of OCD, viz., the deer mouse, to assess complex social behavior in animals by investigating group sociability and its response to chronic escitalopram treatment (50 mg/kg/day × 28 days), both within and between non (N)- (viz., normal) and high (H)- (viz., OCD-like) stereotypical cohorts. Using automated screening, we scored approach behavior, episodes of proximity, duration of proximity, and relative net weighted movement. H animals socialized more with one another within cohort in all of the above parameters compared to the within-cohort behavior of N animals. Furthermore, the social behavior of H animals toward one another, both within and between cohort demonstrated significant improvements following chronic escitalopram treatment. However, the study also demonstrates that the social interaction between H and N animals remain poor even after chronic escitalopram treatment. To conclude, findings from the current investigation support clinical data demonstrating altered sociability in patients with OCD.

Fatigue Experiences Among OCD Outpatients

Patients with OCD are impaired in multiple domains of functioning and quality of life. While associated psychopathology complaints and neuropsychological deficits were reported, the subjective experience of general fatigue and mental fatigue was scarcely investigated. In this single-center case-control study we compared 50 non-depressed OCD outpatients consecutively recruited and 50 panic disorder (PD) outpatients, to determine whether they experienced fatigue differently. Assessment consisted of structured clinical interview for DSM-IV criteria by using the SCID-I and the SCID-II. Symptom severity was assessed using the Yale-Brown Obsessive-Compulsive Scale, the Hamilton Anxiety Rating Scale, the Hamilton Depression Rating Scale, the Clinical Global Impressions Scale, severity and the Global Assessment of Functioning Scale. Fatigue was assessed by using the Multidimensional Fatigue Inventory (MFI). Regarding MFI physical fatigue, an OR of 0.196 (95 % CI 0.080-0.478) was found, suggesting that its presence is associated with lower odds of OCD compared to PD. The same can be said for MFI mental fatigue, as an OR of 0.138 (95 % CI 0.049-0.326) was found, suggesting that its presence is associated with lower odds of OCD. Notably, OCD patients with OCDP co-morbidity reported higher scores of mental fatigue. In this study fatigue, including mental fatigue, seems not to be a prominent experience among adult non-depressed OCD patients.

Obsessive-compulsive symptoms in children and adolescents: symptomatology, impairment and quality of life

Although the "presence of obsessive-compulsive (OC) symptoms" and "OC-related impairment" are the main criteria to diagnose obsessive-compulsive disorder, the significance of symptomatology versus impairment in explaining quality of life remains unclear. The present study relies on two samples including 462 children (8-11 years old) and 265 children and adolescents (10-17 years old) and explores how self-ratings of specific OC symptoms and OC impairment are associated with father ratings of childhood quality of life. Hierarchical regression analysis was used to investigate the additive effect of OC impairment beyond OC symptomatology (and vice versa) in predicting quality of life. The results demonstrated that specific OC symptoms and OC impairment are differentially related to quality of life, underscoring the additive value of OC impairment beyond OC symptomatology, whereas the reverse was not the case. This finding highlights the importance of measuring impairment besides symptomatology to identify those OC features in childhood that are most significantly related to decreased quality of life.