Treatment of refractory obsessive-compulsive disorder: The St. Louis model

Assessing Causal Pathways and Targets of Implementation Variability for EBP use (Project ACTIVE): a study protocol

Background

Advancing causal implementation theory is critical for designing tailored implementation strategies that target specific mechanisms associated with evidence-based practice (EBP) use. This study will test the generalizability of a conceptual model that integrates organizational constructs and behavioral theory to predict clinician use of cognitive-behavioral therapy (CBT) techniques in community mental health centers. CBT is a leading psychosocial EBP for psychiatric disorders that remains underused despite substantial efforts to increase its implementation.

Methods

We will leverage ongoing CBT implementation efforts in two large public health systems (Philadelphia and Texas) to recruit 300 mental health clinicians and 600 of their clients across 40 organizations. Our primary implementation outcomes of interest are clinician intentions to use CBT and direct observation of clinician use of CBT. As CBT comprises discrete components that vary in complexity and acceptability, we will measure clinician use of six discrete components of CBT. After finishing their CBT training, participating clinicians will complete measures of organizational and behavior change constructs delineated in the model. Clinicians also will be observed twice via audio recording delivering CBT with a client. Within 48 h of each observation, theorized moderators of the intention-behavior gap will be collected via survey. A subset of clinicians who report high intentions to use CBT but demonstrate low use will be purposively recruited to complete semi-structured interviews assessing reasons for the intention-behavior gap. Multilevel path analysis will test the extent to which intentions and determinants of intention predict the use of each discrete CBT component. We also will test the extent to which theorized determinants of intention that include psychological, organizational, and contextual factors explain variation in intention and moderate the association between intentions and CBT use.

Discussion

Project ACTIVE will advance implementation theory, currently in its infancy, by testing the generalizability of a promising causal model of implementation. These results will inform the development of implementation strategies targeting modifiable factors that explain substantial variance in intention and implementation that can be applied broadly across EBPs.

Knowledge and competency standards for specialized cognitive behavior therapy for adult obsessive-compulsive disorder

Obsessive-Compulsive Disorder (OCD) is a leading cause of disability world-wide (World Health Organization, 2008). Treatment of OCD is a specialized field whose aim is recovery from illness for as many patients as possible. The evidence-based psychotherapeutic treatment for OCD is specialized cognitive behavior therapy (CBT, NICE, 2005, Koran and Simpson, 2013). However, these treatments are not accessible to many sufferers around the world. Currently available guidelines for care are deemed to be essential but insufficient because of highly variable clinician knowledge and competencies specific to OCD. The phase two mandate of the 14 nation International OCD Accreditation Task Force (ATF) created by the Canadian Institute for Obsessive Compulsive Disorders is development of knowledge and competency standards for specialized treatments for OCD through the lifespan deemed by experts to be foundational to transformative change in this field. This paper presents knowledge and competency standards for specialized CBT for adult OCD developed to inform, advance, and offer a model for clinical practice and training for OCD. During upcoming ATF phases three and four criteria and processes for training in specialized treatments for OCD through the lifespan for certification (individuals) and accreditation (sites) will be developed based on the ATF standards.

Effects of Treatment Setting on Outcomes of Flexibly-Dosed Intensive Cognitive Behavioral Therapy for Pediatric OCD: A Randomized Controlled Pilot Trial

Introduction: Optimizing individual outcomes of cognitive-behavioral therapy (CBT) remains a priority. Methods: Youth were randomized to receive intensive CBT at a hospital clinic (n = 14) or within their home (n = 12). Youth completed 3 × 3 h sessions (Phase I) and up to four additional 3-h sessions as desired/needed (Phase II). An independent evaluator assessed youth after Phase I, Phase II (when applicable), and at 1- and 6-months post-treatment. A range of OCD-related (e.g., severity, impairment) and secondary (e.g., quality of life, comorbid symptoms) outcomes were assessed. Results: Families' satisfaction with the treatment program was high. Of study completers (n = 22), five youth (23%) utilized no Phase II sessions and 9 (41%) utilized all four (Median Phase II sessions: 2.5). Large improvements in OCD-related outcomes and small-to-moderate benefits across secondary domains were observed. Statistically-significant differences in primary outcomes were not observed between settings; however, minor benefits for home-based treatment were observed (e.g., maintenance of gains, youth comfort with treatment). Discussion: Intensive CBT is an efficacious treatment for pediatric OCD. Families opted for differing doses based on their needs. Home-based treatment, while not substantially superior to hospital care, may offer some value, particularly when desired/relevant. Clinical Trial Registration: www.ClinicalTrials.gov; https://clinicaltrials.gov/ct2/show/NCT03672565, identifier: NCT03672565.

Personality traits in adults with hoarding disorder

BACKGROUND

Prior research has demonstrated a link between compulsive hoarding symptoms and personality traits; however, no studies have investigated the link between hoarding and personality traits utilizing a sample of individuals diagnosed with hoarding disorder (HD) using formal diagnostic criteria. The aim of the current study was to evaluate the frequency and type of personality traits in adults diagnosed with HD and to explore the associations among hoarding severity and personality disorder traits within this sample.

METHODS

Seventy-two veterans enrolled in an ongoing treatment trial for HD completed a battery of self-report measures during their initial assessment. Linear regression analyses were used to determine the unique variance accounted for by hoarding severity in predicting scores on the personality disorder scales from the Millon Clinical Multiaxial Inventory-III (MCMI-III).

RESULTS

The majority of participants had an elevated score on at least one of the MCMI-III Personality scales. The most frequently elevated scores were for the Avoidant, Dependent, Depressive, and Schizoid scales. Hoarding severity was a significant predictor of personality traits in 10 out of 14 MCMI-III scales.

LIMITATIONS

Given the exploratory nature of the investigation, we did not control for multiple comparisons or the presence of mood or anxiety disorders.

CONCLUSIONS

The elevated prevalence of co-occurring personality pathology in adults with HD indicates the importance of considering underlying personality structure when developing individualized treatment plans.

The heterogeneous course of OCD - A scoping review on the variety of definitions

Although effective treatments exist, obsessive-compulsive disorder (OCD) is, according to the views of patients and experts, still associated with chronicity, a term with no clear and consistent definition. To improve patient care and to foster research, a clear distinction between the various concepts of chronicity cited in the literature is crucial. The aim was thus to explicate central concepts related to courses and trajectories in OCD based on an explorative, scoping search of the existing literature. Our review revealed a considerable lack in content validity, as the concepts were operationalized inconsistently. Concepts related to symptom improvement were (complete) recovery, partial/full remission and partial/full response. Terms used in relation with symptom stability or worsening were chronic/continuous, intermittent and episodic course, waxing and waning, relapse, recurrence, deterioration and treatment-refractoriness. All concepts are explained and visualized as a result of the review. Further, based on authors' remarks, we present recommendations on how to enhance care for chronic OCD patients, namely training psychotherapists to apply CBT as intended, managing patient beliefs about disease and treatment, and adapting psychotherapy to OCD subtypes. Finally, we then propose a literature-based definition of treatment-refractory OCD.

Medication Saving Behaviors of Older Adults: Scale Developed to Assess Family Caregiver Perspectives

OBJECTIVES

This study developed and explored the preliminary reliability and validity of a 6-item Medication Saving Behaviors (MSB) scale when completed by family care partners of older adults.

METHODS

Women (N = 119) helping an aging relative with healthcare appointments and medication management completed an online survey including items related to generalized hoarding and medication saving behaviors.

RESULTS

The MSB was psychometrically sound and correlated significantly with hoarding scales and reported number of expired and leftover medications. Compared with those reporting low levels of general hoarding concerns, group means on the MSB were higher for caregivers reporting clinically significant levels of hoarding by their elderly family member. The MSB was unrelated to total prescription or over-the-counter medications for the older adult, lending support for the discriminant validity of the scale.

CONCLUSIONS

This study provides initial support for the convergent and discriminant validity of the MSB when administered to intergenerational care partners of older adults.

CLINICAL IMPLICATIONS

The MSB may function to identify higher risk patients via their family members and target families for interventions.

Treatment fears in anxiety disorders: development and validation of the treatment ambivalence questionnaire

OBJECTIVES

There are a number of effective psychological interventions for anxiety disorders. Anecdotal and empirical evidence indicates that clients are often highly apprehensive about commencing therapy. However, to date, there have been no empirical studies of the content of individuals' fears about beginning a psychological treatment for anxiety problems. Here we describe the development and initial validation of the Treatment Ambivalence Questionnaire (TAQ), a 30-item self-report measure of concerns about commencing psychological treatment for anxiety.

METHODS

Participants were a large group of individuals with a principal diagnosis of an anxiety disorder who were referred to a specialty anxiety disorders clinic. Participants completed the TAQ as well as several general self-report instruments before commencing treatment.

RESULTS

The TAQ exhibited good internal consistency and, based on exploratory factor analyses, the items yielded three subscales: (a) fears of the personal consequences of engaging in treatment (e.g., personality change), (b) fears of negative or adverse reactions to treatment (e.g., not getting better), and (c) concerns about the inconvenience of engaging in treatment (e.g., treatment will be time-consuming). Confirmatory factor analysis supported this factor structure. Scores on the TAQ did not simply represent general symptom severity or distress. Preliminary data on the relation of TAQ scores to treatment outcome suggested either no relationship or a small relationship.

CONCLUSION

The TAQ may be a useful means of normalizing treatment fears, identifying and addressing specific fears, and identifying people who may benefit from treatment readiness interventions.

Does time-intensive ERP attenuate the negative impact of comorbid personality disorders on the outcome of treatment-resistant OCD?

BACKGROUND AND OBJECTIVES

There is growing interest regarding patients with obsessive-compulsive disorder (OCD) who do not fully respond to cognitive-behavioural therapy (CBT). Limited data are available on the role of Comorbid Personality Disorders (CPDs) in the outcome of treatment-resistant obsessive-compulsive disorder (OCD), despite the fact that CPDs are considered a predictor of a poorer outcome. This study investigated whether a time-intensive scheduling of treatment could be an effective strategy aimed at attenuating the negative influence of CPDs on outcome in a sample of 49 inpatients with a primary diagnosis of treatment-resistant OCD.

METHOD

38 inpatients completed the five-week individual treatment consisting of daily and prolonged sessions of exposure with response prevention (ERP) delivered for 2 h in the morning and 2 h in the afternoon. 44% of the sample received a full diagnosis of one or more CPDs. Following a pre-post-test design, outcome measures included the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Beck Depression Inventory-II (BDI-II) and Beck Anxiety Inventory (BAI).

RESULTS

Data showed that the treatment was effective and indicated that CPDs were not a significant predictor of treatment failure.

LIMITATIONS

Future larger studies should evaluate the role of specific clusters of CPDs on the outcome of resistant OCD.

CONCLUSIONS

These findings suggest that an intensive treatment could be effective for severely ill patients who have not responded to weekly outpatient sessions and could also attenuate the negative impact of CPDs on outcome, evidencing the importance of a tailored therapeutic approach for patients who need a rapid reduction in OCD-related impairment.

Which Client Characteristics Contribute to Good and Poor Cognitive-Behavioural Treatment Outcome for Social Anxiety Disorder? A Survey of Clinicians

The aim of the study was to survey a group of clinicians who identify themselves as experienced in treating social anxiety disorder using cognitive behavioural treatment (CBT) with regard to the characteristics of clients which they think, based on their experience, are predictive of poor or good CBT outcome. Fifty-four practising clinicians responded to an email inviting participation in a research study of clinicians’ opinions about client characteristics that may be important in CBT outcome for social anxiety. Participants completed open-ended questions about, and made ratings of the importance of, client characteristics that they believed impact upon the outcome of CBT for social anxiety disorder. Motivation for seeking treatment, comorbidity, and intellect or reasoning ability were nominated most frequently by clinicians as having an effect on CBT outcome. Acceptance of the CBT rationale/model, ability to take responsibility for change, motivation/reason for seeking treatment, and ability to develop an alliance were all rated by participants as being important in contributing to CBT outcome. The results provide direction for future empirical research on client characteristics as predictors of CBT outcome.

Obsessive-compulsive disorder: diagnostic and treatment issues

This article reviews current issues in the diagnosis and treatment of obsessive-compulsive disorder (OCD). The introduction of the selective serotonin reuptake inhibitors and of cognitive-behavioral therapy were significant advances for treating OCD. Nevertheless, there is a need to improve awareness of OCD and its management, and to develop novel approaches to treatment-refractory patients. Although the diagnostic criteria for OCD have remained unchanged for some time, there are several areas where potential modification may be useful. There is a growing evidence base on OCD symptom dimensions and subtyping, and it is timely to consider incorporating some of these emerging data into diagnostic classification systems.

An effectiveness study of group therapy for anxiety disorders

This work examines the transportability of group cognitive-behavioral therapy (GCBT) for a wide range of anxiety disorders to a college counseling center. Participants were 31 clients with a primary diagnosis of generalized anxiety disorder, panic disorder with agoraphobia, social phobia, specific phobia, or obsessive-compulsive disorder who identified dysfunction in one or more of eight daily function areas. Clients were not excluded on the basis of medication use, severity or frequency of panic attacks, age, or comorbidity. Of the 31 participants, there were 17 treatment completers, defined by a minimum of 20 sessions in a flexibly bounded psychotherapy group, who achieved significant reductions in levels of anxiety-related dysfunction. The present study suggests that group cognitive behavioral therapy can be transported to a college counseling center.