The nature and correlates of avoidance in obsessive-compulsive disorder

Optimizing Obsessive-Compulsive Symptom Measurement With the Yale-Brown Obsessive-Compulsive Scales-Second Edition

The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) is a widely used measure for assessing the presence and severity of obsessive-compulsive disorder symptoms. The Yale-Brown Obsessive-Compulsive Scale-Second Edition (Y-BOCS-II) was developed, in part, to more comprehensively evaluate symptom severity, especially in extremely ill patients, and improve consistency in detecting and incorporating avoidance behaviors. We present 3 case studies that demonstrate the enhanced ability of the Y-BOCS-II to: (1) detect fluctuations in symptom severity among extremely ill patients, (2) systematically incorporate avoidance variables for more accurate ratings, and (3) maintain strong convergence with the Y-BOCS in assessing patients presenting with mild to moderate symptoms. In addition, we outline how to obtain both Y-BOCS and Y-BOCS-II scores within 1 administration by adding Y-BOCS item 4 to the Y-BOCS-II assessment, then "back-coding" the Y-BOCS-II ratings to Y-BOCS ratings and using Y-BOCS item 4 in place of Y-BOCS-II item 2. The use of this method allows for more robust data collection while providing comparability across the literature.

Best practices for CBT treatment of taboo and unacceptable thoughts in OCD

Although general cognitive behavioural therapy (CBT) can help alleviate distress associated with obsessive-compulsive disorder (OCD), strategies tailored to targeting specific cognitions, feelings, and behaviours associated with OCD such as exposure and ritual prevention (Ex/RP) and cognitive therapy (CT) have been shown to be a significantly more effective form of treatment. Treatment of individuals with unacceptable/taboo obsessions requires its own specific guidelines due to the stigmatizing and often misunderstood nature of accompanying thoughts and behaviours. In this article, OCD expert practitioners describe best practices surrounding two of the longest standing evidence-based treatment paradigms for OCD, CT and Ex/RP, tailored specifically to unacceptable and taboo obsessions, so that clients may experience the best possible outcomes that are sustained once treatment ends. In addition, CT specifically targets obsessions while Ex/RP addresses compulsions, allowing the two to be highly effective when combined together. A wide range of clinical recommendations on clinical competencies is offered, including essential knowledge, psychoeducation, designing fear hierarchies and exposures, instructing the client through behavioural experiments, and relapse prevention skills.

Key learning aims

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Symptoms of Obsessive-Compulsive Disorder during Pregnancy and the Postpartum Period: a Systematic Review and Meta-Analysis

The main aim of this systematic review and meta-analysis was to calculate and compare the frequencies of obsessions and compulsions in women with obsessive-compulsive disorder (OCD) during pregnancy (OCD-P), the postpartum period (OCD-PP) and when they are neither pregnant nor postpartum (OCD-NPP). Fourteen studies were selected after applying the inclusion and exclusion criteria. The meta-analysis showed that aggressive obsessions were much more common in OCD-PP than in OCD-P and OCD-NPP and that washing/cleaning compulsions were less frequent in OCD-PP than in OCD-P and OCD-NPP. These differences were significant, whereas the frequencies of various obsessions and compulsions did not distinguish between OCD-P and OCD-NPP. Obsessions about accidental harm to the infant and other infant-focused obsessions, checking compulsions, self-reassurance and seeking reassurance from others were also relatively common in OCD-PP. Clinical manifestations of OCD-PP are relatively specific and differ from those of OCD-P and OCD-NPP, whereas OCD-P does not seem to have distinct clinical features. Although these findings do not necessarily suggest that OCD-PP is a distinct subtype of OCD, they have important conceptual and clinical implications.

Avoidance, Insight, Impairment Recognition Concordance, and Cognitive-Behavioral Therapy Outcomes in Pediatric Obsessive-Compulsive Disorder

OBJECTIVE

Insight and avoidance are commonly discussed factors in obsessive-compulsive disorder (OCD) that have demonstrated associations with increased severity as well as reduced treatment response in adults, but these factors have not been sufficiently examined in pediatric OCD. This study examined the impacts of avoidance, insight, and impairment recognition concordance on cognitive-behavioral therapy (CBT) outcomes as well as impacts of CBT on insight and avoidance in a large sample of youths affected by OCD.

METHOD

Data from 573 OCD-affected youths enrolled in CBT trials were aggregated. Children's Yale-Brown Obsessive-Compulsive Scale items measured treatment response, insight, and avoidance. Standardized differences between child and parent ratings of impairment were used to calculate impairment recognition concordance. Binary logistic regression was used to identify variables associated with treatment response.

RESULTS

Greater avoidance, limited child recognition of impairment, older age, and lower baseline severity predicted reduced likelihood of treatment response, but insight did not. Both insight and avoidance improved significantly following CBT. Response rates were lower when posttreatment insight and avoidance were worse.

CONCLUSION

Contrasting with prevailing belief, poor insight does not appear to limit CBT response potential in pediatric OCD. Avoidance and impairment recognition are understudied CBT response predictors and warrant further consideration in pediatric OCD. Clinicians should attend to these factors to optimize outcomes for children affected by this common, debilitating illness.

Responsibility/Threat Overestimation Moderates the Relationship Between Contamination-Based Disgust and Obsessive-Compulsive Concerns About Sexual Orientation

Disgust has been shown to perform a "disease-avoidance" function in contamination fears. However, no studies have examined the relevance of disgust to obsessive-compulsive (OC) concerns about sexual orientation (e.g., fear of one's sexual orientation transforming against one's will, and compulsive avoidance of same-sex and/or gay or lesbian individuals to prevent that from happening). Therefore, we investigated whether the specific domain of contamination-based disgust (i.e., evoked by the perceived threat of transmission of essences between individuals) predicted OC concerns about sexual orientation, and whether this effect was moderated/amplified by obsessive beliefs, in evaluation of a "sexual orientation transformation-avoidance" function. We recruited 283 self-identified heterosexual college students (152 females, 131 males; mean age = 20.88 years, SD = 3.19) who completed three measures assessing disgust, obsessive beliefs, and OC concerns about sexual orientation. Results showed that contamination-based disgust (β = .17), responsibility/threat overestimation beliefs (β = .15), and their interaction (β = .17) each uniquely predicted OC concerns about sexual orientation, ts = 2.22, 2.50, and 2.90, ps < .05. Post hoc probing indicated that high contamination-based disgust accompanied by strong responsibility/threat overestimation beliefs predicted more severe OC concerns about sexual orientation, β = .48, t = 3.24, p < .001. The present study, therefore, provided preliminary evidence for a "sexual orientation transformation-avoidance" process underlying OC concerns about sexual orientation in heterosexual college students, which is facilitated by contamination-based disgust, and exacerbated by responsibility/threat overestimation beliefs. Treatment for OC concerns about sexual orientation should target such beliefs.

Behavioral avoidance predicts treatment outcome with exposure and response prevention for obsessive-compulsive disorder

BACKGROUND

Many individuals with obsessive-compulsive disorder (OCD) display behavioral avoidance related to their obsessional thoughts and compulsive behaviors. However, how these avoidance behaviors impact treatment outcomes with exposure and response prevention (EX/RP) remains unclear. We examined pretreatment avoidance behaviors as predictors of EX/RP outcomes.

METHODS

Data came from a randomized controlled trial of augmentation strategies for inadequate response to serotonin reuptake inhibitors comparing EX/RP (N = 40), risperidone (N = 40), and placebo (N = 20). Baseline avoidance was rated with the avoidance item from the Yale-Brown Obsessive-Compulsive Scale (YBOCS). Primary analyses examined avoidance behaviors as predictors of EX/RP outcomes. To test specificity, we explored whether avoidance also related to outcomes among patients receiving risperidone and placebo.

RESULTS

More than half (69%) of the full sample had moderate or severe avoidance behaviors at baseline. In EX/RP, controlling for baseline severity, pretreatment avoidance predicted posttreatment YBOCS symptoms (β = 0.45, P < .01). Avoidant individuals were less likely to achieve remission with EX/RP (odds ratio = 0.04, 95% confidence interval [CI] range 0.01-0.28, P = .001). Baseline avoidance was also associated with degree of patient adherence to between-session EX/RP assignments, which mediated the relationship between baseline avoidance and EX/RP outcomes (P < .05). Baseline avoidance did not predict outcomes or wellness among patients receiving risperidone or placebo.

CONCLUSIONS

These results suggest that avoidance behaviors are an important clinical factor in EX/RP outcomes and indicate that assessing avoidance may provide an efficient method for predicting EX/RP outcomes. Avoidance may be particularly relevant in EX/RP as compared to medication treatment, though future replication of these initial results is required.

Panic Disorder and Agoraphobia in OCD patients: clinical profile and possible treatment implications

OBJECTIVE

Panic Disorder (PD) and agoraphobia (AG) are frequently comorbid with obsessive-compulsive disorder (OCD), but the correlates of these comorbidities in OCD are fairly unknown. The study aims were to: 1) estimate the prevalence of PD with or without AG (PD), AG without panic (AG) and PD and/or AG (PD/AG) in a large clinical sample of OCD patients and 2) compare the characteristics of individuals with and without these comorbid conditions.

METHOD

A cross-sectional study with 1001 patients of the Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders using several assessment instruments, including the Dimensional Yale-Brown Obsessive-Compulsive Scale and the Structured Clinical Interview for DSM-IV-TR Axis I Disorders. Bivariate analyses were followed by logistic regression models.

RESULTS

The lifetime prevalence of PD was 15.3% (N=153), of AG 4.9% (N=49), and of PD/AG 20.2% (N=202). After logistic regression, hypochondriasis and specific phobia were common correlates of the three study groups. PD comorbidity was also associated with higher levels of anxiety, having children, major depression, bipolar I, generalized anxiety and posttraumatic stress disorders. Other independent correlates of AG were: dysthymia, bipolar II disorder, social phobia, impulsive-compulsive internet use, bulimia nervosa and binge eating disorder. Patients with PD/AG were also more likely to be married and to present high anxiety, separation anxiety disorder, major depression, impulsive-compulsive internet use, generalized anxiety, posttraumatic stress and binge eating disorders.

CONCLUSIONS

Some distinct correlates were obtained for PD and AG in OCD patients, indicating the need for more specific and tailored treatment strategies for individuals with each of these clinical profiles.

The characteristics of unacceptable/taboo thoughts in obsessive-compulsive disorder

BACKGROUND

In the quest to unravel the heterogeneity of obsessive-compulsive disorder (OCD), an increasing number of factor analytic studies are recognising unacceptable/taboo thoughts as one of the symptom dimensions of OCD.

AIMS

This study aims to examine the characteristics associated with unacceptable/taboo thoughts.

METHODS

Using the Yale-Brown Obsessive-Compulsive Scale Symptom Checklist (YBOCS-SC) with 154 individuals with OCD, obsessive-compulsive symptoms were subjected to principal components analysis. The characteristics associated with the resulting symptom dimensions were then assessed using logistic and linear regression techniques.

RESULTS

Unacceptable/taboo thoughts comprised of sexual, religious and impulsive aggressive obsessions, and mental rituals. Higher scores on an unacceptable/taboo thoughts symptom dimension were predicted by higher Y-BOCS obsession subscores, Y-BOCS time preoccupied by obsessions scores, Y-BOCS distress due to obsessions scores, importance of control of thought ratings, male gender, and having had treatment prior to entering into the study. Unacceptable/taboo thoughts were also predicted by greater levels of hostility, and a past history of non-alcohol substance dependence.

CONCLUSIONS

An unacceptable/taboo thought symptom dimension of OCD is supported by a unique set of associated characteristics that should be considered in the assessment and treatment of individuals with these symptoms.

The use of psychotropic agents for the symptoms of obsessive-compulsive disorder

OBJECTIVE

To describe the use of psychotropic agents in a sample of subjects with obsessive-compulsive disorder (OCD), and in particular the differences associated with different OCD symptoms.

METHOD

A total of 154 subjects participated in a study assessing OCD symptom subtypes, called the Nepean OCD Study. In addition to a comprehensive evaluation of the subjects' OCD symptoms using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Vancouver Obsessive-Compulsive Inventory (VOCI), and the Sheehan Disability Scale (SDS), the subjects' medication history was recorded. The association between symptom severity, disability, OCD symptom subtypes and the use of psychotropic agents was examined.

RESULTS

Psychotropic medication was taken by 93 (60.4%) participants. In the majority of cases (n=55, 59.1%), selective serotonin reuptake inhibitors (SSRIs) were taken, and of the SSRIs, the most commonly used agent was escitalopram (n=21, 22.6%). Psychotropic agents were more likely to be taken by subjects with higher Y-BOCS and SDS scores. Hoarding was associated with a lower likelihood of psychotropic use, whereas unacceptable/taboo thoughts were associated with an increased likelihood of psychotropic and antipsychotic use.

CONCLUSION

Patients with OCD are more likely to be taking psychotropic agents if they have a more severe illness, greater disability and more prominent unacceptable/taboo thoughts.

Obsessive-compulsive personality disorder co-occurring with obsessive-compulsive disorder: Conceptual and clinical implications

OBJECTIVES

There are ongoing uncertainties in the relationship between obsessive-compulsive disorder (OCD) and obsessive-compulsive personality disorder (OCPD). This study aimed to test the proposition that OCPD may be a marker of severity of OCD by comparing groups of OCD individuals with and without OCPD on a number of variables.

METHOD

A total of 148 adults with a principal diagnosis of OCD were administered the Mini International Neuropsychiatric Interview, Yale-Brown Obsessive-Compulsive Scale, Sheehan Disability Scale, Vancouver Obsessional Compulsive Inventory and Symptom Checklist 90-Revised. Participants with a DSM-IV diagnosis of OCPD were compared with those without OCPD.

RESULTS

Some 70 (47.3%) participants were diagnosed with OCPD. The groups of participants with and without OCPD did not differ significantly with respect to any of the demographic variables, clinician-rated severity of OCD, levels of disability and mean age of onset of OCD. All self-rated OCD symptom dimensions except for contamination and checking were significantly more prominent in participants with OCPD, as were all self-rated dimensions of psychopathology. Participants with OCPD had significantly more frequent hoarding compulsions and obsessions involving a need to collect and keep objects. Of Axis I disorders, only panic disorder was significantly more frequent in participants with OCPD than in those without OCPD.

CONCLUSIONS

A high frequency of OCPD among individuals with OCD suggests a strong, although not necessarily a unique, relationship between the two conditions. This finding may also be a consequence of the blurring of the boundary between OCD and OCPD by postulating that hoarding and hoarding-like behaviours characterise both disorders. Results of this study do not support the notion that OCD with OCPD is a marker of clinician-rated severity of OCD. However, individuals with OCPD had more prominent OCD symptoms, they were more distressed and exhibited various other psychopathological phenomena more intensely, which is likely to complicate their treatment.