Adherence to exposure and response prevention as a predictor of improvement in obsessive-compulsive symptom dimensions

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.

A Randomized Controlled Trial of OC-Go for Childhood Obsessive-Compulsive Disorder: Augmenting Homework Compliance in Exposure With Response Prevention Treatment

The current study investigates a novel digital tool designed to address barriers to out-of-session homework adherence in exposure with response prevention (ERP) for child obsessive-compulsive disorder (OCD). The OC-Go platform allows clinicians to create and push tailored interactive protocol- or symptom-specific assignments to patients on their mobile devices, providing in-the-moment step-by-step directions, encouragement, accountability, and a sense of therapeutic presence for patients during out-of-office exposures. The platform also facilitates objective measurement of homework and allows providers to support one another through a shared and searchable crowdsourced library with hundreds of assignable exposures and psychoeducation activities for specific OCD symptoms. The current study tested the usability and feasibility of the OC-Go platform with ERP stakeholders (OCD therapists, patients, and parents; N = 172) using the System Usability Scale (SUS). The study also tested the efficacy of OC-Go for augmenting homework adherence and clinical response using a randomized controlled, crossover design in a sample of 28 treatment-seeking youth with OCD. Participants randomized to standard ERP exhibited a homework adherence rate of 68.4% (95% CI [65.6, 71.0]), those randomized to ERP with OC-Go exhibited a greater adherence rate of 83.3% (95% CI [80.8, 85.6], p < .001). Both groups experienced large declines in Children's Yale-Brown Obsessive-Compulsive Scale-rated OCD (d = 1.31, p < .001), though participants randomized to begin ERP with OC-Go exhibited clinically significant greater improvement (p = .05), translating into an additional augmented treatment response at the Week 6 primary end point (d = 0.36) and the Week 12 treatment end point (d = 0.72). Stakeholders rated OC-Go in the 90th percentile for usability on the SUS, indicative of a highly usable and easy-to-learn technology. Initial evidence supports OC-Go as a feasible and effective adjunct to improve out-of-office exposure measurement, adherence, and treatment response in ERP for child OCD.

Large nesting expression in deer mice remains stable under conditions of visual deprivation despite heightened limbic involvement: Perspectives on compulsive-like behavior

Visual stimuli and limbic activation varyingly influence obsessive-compulsive symptom expression and so impact treatment outcomes. Some symptom phenotypes, for example, covert repugnant thoughts, are likely less sensitive to sensory stimuli compared to symptoms with an extrinsic focus, that is, symptoms related to contamination, safety, and "just-right-perceptions." Toward an improved understanding of the neurocognitive underpinnings of obsessive-compulsive psychobiology, work in naturalistic animal model systems is useful. Here, we explored the impact of visual feedback and limbic processes on 24 normal (NNB) and large (LNB) nesting deer mice, respectively (as far as possible, equally distributed between sexes). Briefly, after behavioral classification into either the NNB or LNB cohorts, mice of each cohort were separated into two groups each and assessed for nesting expression under either standard light conditions or conditions of complete visual deprivation (VD). Nesting outcomes were assessed in terms of size and neatness. After nesting assessment completion, mice were euthanized, and samples of frontal-cortical and hippocampal tissues were collected to determine serotonin and noradrenaline concentrations. Our results show that LNB, as opposed to NNB, represents an inflexible and excessive behavioral phenotype that is not dependent on visually guided action-outcome processing, and that it associates with increased frontal-cortical and hippocampal noradrenaline concentrations, irrespective of lighting condition. Collectively, the current results are informing of the neurocognitive underpinnings of nesting behavior. It also provides a valuable foundation for continued investigations into the noradrenergic mechanisms that may influence the development and promulgation of excessive, rigid, and inflexible behaviors.

Provider perceptions of telehealth and in-person exposure and response prevention for obsessive-compulsive disorder

Until recently, psychotherapies, including exposure and response prevention (ERP) for obsessive-compulsive disorder (OCD), have primarily been delivered in-person. The COVID-19 pandemic required OCD providers delivering ERP to quickly transition to telehealth services. While evidence supports telehealth ERP delivery, limited research has examined OCD provider perceptions about patient characteristics that are most appropriate for this modality, as well as provider abilities to identify and address factors interfering with effective telehealth ERP. In the present study, OCD therapists (N = 113) rated the feasibility of delivering telehealth ERP relative to in-person for different (1) patient age-groups, (2) levels of OCD severity, and (3) provider ability to identify and address factors interfering with ERP during in-person and telehealth ERP (e.g., cognitive avoidance, reassurance seeking, etc.). Providers reported significantly greater feasibility of delivering telehealth ERP to individuals ages 13-to-65-years relative to other age groups assessed. Greater perceived feasibility for telehealth relative to in-person ERP was reported for lower versus higher symptom severity levels. Lastly, providers felt better able to identify and address problematic factors in-person. These findings suggest that providers should practice appropriate caution when offering telehealth ERP for certain patients with OCD. Future research may examine how to address these potential limitations of telehealth ERP delivery.

Fear conditioning and extinction in obsessive-compulsive disorder: A systematic review

Laboratory experiments using fear conditioning and extinction protocols help lay the groundwork for designing, testing, and optimizing innovative treatments for anxiety-related disorders. Yet, there is limited basic research on fear conditioning and extinction in obsessive-compulsive disorder (OCD). This is surprising because exposure-based treatments based on associative learning principles are among the most popular and effective treatment options for OCD. Here, we systematically review and critically assess existing aversive conditioning and extinction studies of OCD. Across 12 studies, there was moderate evidence that OCD is associated with abnormal acquisition of conditioned responses that differ from comparison groups. There was relatively stronger evidence of OCD's association with impaired extinction processes. This included multiple studies finding elevated conditioned responses during extinction learning and poorer threat/safety discrimination during recall, although a minority of studies yielded results inconsistent with this conclusion. Overall, the conditioning model holds value for OCD research, but more work is necessary to clarify emerging patterns of results and increase clinical translational utility to the level seen in other anxiety-related disorders. We detail limitations in the literature and suggest next steps, including modeling OCD with more complex conditioning methodology (e.g., semantic/conceptual generalization, avoidance) and improving individual-differences assessment with dimensional techniques.

Association between obsessive-compulsive and related disorders and experiential avoidance: A systematic review and meta-analysis

The associations between the distinct types of obsessive-compulsive and related disorders and experiential avoidance have received mixed evidence. We, thus, undertook this meta-analysis to i) re-examine the association between obsessive-compulsive disorder and experiential avoidance, ii) extend this association to hoarding disorder, trichotillomania, and body dysmorphic disorder, and iii) identify potential variables affecting these associations. Five databases, including Medline, Embase, PsychINFO, Web of Science and CINAHL, were searched until March 15th, 2021. Meta-analyses based on random-effect models were performed. Heterogeneity and publication bias tests were applied using the I² statistic and the Egger's test. Meta-regression analyses were performed to identify potential moderators affecting the strength of these associations. Thirty-six unique studies based on n = 11,859 participants were identified. The association between obsessive-compulsive disorder and experiential avoidance was moderate (SMD = 0.75, 95% CI = 0.57-0.92), whereas the associations between individual obsessive-compulsive symptoms, including obsessions, responsibility for harm, ordering, checking, washing and neutralizing, and experiential avoidance ranged from low to strong (SMD ranged between 0.41 and 1.06, 95% CI = 0.25 to 1.40). The associations between hoarding disorder (SMD = 0.93, 95% CI = 0.46-1.40), trichotillomania (SMD = 0.56, 95% CI = 0.48-0.63), body dysmorphic disorder (SMD = 1.55, 95% CI = 0.72-2.37) and experiential avoidance were moderate to strong. Meta-regression analyses demonstrated that studies using the AAQ/AAQ-II scales for measuring experiential avoidance, and/or self-report scales for assessing OCRDs contributed smaller effect sizes. These findings suggest that reducing experiential avoidance may be a viable way of complementing exposure strategies in alleviating obsessive-compulsive and related symptoms.

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.