Loneliness in OCD and its determinants.

Obsessive-compulsive disorder (OCD) is a psychiatric condition characterized by intrusive thoughts and repetitive behaviors, affecting approximately 1.3 % of the population. Loneliness has serious consequences for future health outcomes. Although it has been extensively studied in depression, its prevalence in obsessive-compulsive disorder (OCD) has hardly been investigated. The current study sought to examine the association between loneliness and OCD, through an exploratory investigation of their demographic and clinical correlates. This cross-sectional study utilized data from the Netherlands Obsessive-Compulsive Disorder Association (NOCDA) study, designed to investigate determinants, course, and consequences of OCD in a large clinical sample. In this data base, a cohort of 363 OCD adult patients underwent assessment for loneliness severity, OCD symptomatology, comorbid conditions, and demographic variables. Findings reveal a high prevalence of loneliness among OCD patients, with nearly three-quarters (73.6 %) experiencing elevated levels. Loneliness was associated with greater depression severity and specific demographic factors such as gender, age, and education level. However, the relationship between OCD severity and loneliness was explained by depression severity. Clinical and theoretical implications are discussed as well as limitations and directions for future research.

The role of emotion recognition in reappraisal affordances.

INTRODUCTION: Emotion regulation is essential for psychological well-being. One strategy that is commonly researched is reappraisal. Individual differences regarding the tendency to use reappraisal, as well as its implications for affective experience, were extensively studied. In recent years, interest has emerged in the choice to use reappraisal, based on stimuli properties. Recently, we suggested that reappraisal is related to emotion recognition processes. Emotion recognition (and affective labeling, as an explicit form of emotion recognition) is regarded as a form of emotion regulation, however, the relations between emotion recognition and reappraisal have not been previously investigated. The aim of the current study was to explore the relationship between reappraisal affordances (the opportunities of re-interpretation that are inherent in a stimulus) and emotion recognition. METHOD: For this purpose, we used the Categorized Affective Picture Database, a database that provides data regarding the emotional category of each picture, agreement levels for each category, and intensity ratings. Agreement levels were used to assess the certainty regarding the emotion evoked by the pictures. RESULTS: Findings suggest that reappraisal affordance is predicted by both agreement levels and intensity, in negative pictures alone. In negative pictures, intensity was negatively correlated with the difficulty to reappraise. DISCUSSION: These findings strengthen the hypothesis regarding the relationship between emotion recognition and reappraisal, and provide evidence for the role of emotion recognition in reappraisal affordances.

Long-term remission rates and trajectory predictors in obsessive-compulsive disorder: Findings from a six-year naturalistic longitudinal cohort study.

BACKGROUND: This naturalistic study, utilizing data from the Netherlands Obsessive-Compulsive Disorder Association (NOCDA) cohort, investigated the long-term remission rates and predictors of different trajectories of obsessive-compulsive disorder (OCD) within a clinical population. METHODS: A sample of 213 participants was classified into three illness trajectories: "Chronic," "Episodic, "and "Remitted-OCD." Long-term remission rates were calculated based on three follow-up measurements over a 6-year period. A multinomial logistic regression model, incorporating five selected predictors with high explanatory power and one covariate, was employed to analyze OCD trajectory outcomes. RESULTS: The long-term full remission rates, calculated from all the measurements combined (14%), were significantly lower than what was observed in earlier studies and when compared to assessments at each individual follow-up (∼30%). Moreover, high baseline symptom severity and early age of onset were identified as significant risk factors for a chronic course of OCD, while male sex and younger age predicted a more favorable trajectory. Notably, the likelihood of an episodic course remained high even without identified risk factors. LIMITATIONS: The bi-annual data collection process is unable to capture participants' clinical conditions between assessments. Additionally, no data was collected regarding the specific type and duration of psychological treatment received. Regarding the type of treatment participants received. CONCLUSIONS: Results suggest that long-term remission rates may be lower than previously reported. Consequently, employing multiple assessment points in longitudinal studies is necessary for valid estimation of long-term full remission rates. The results emphasize the importance of personalized clinical care and ongoing monitoring and maintenance for most OCD cases.

Predictors of the 6-year outcome of obsessive-compulsive disorder: Findings from the Netherlands Obsessive-Compulsive Disorder Association study.

OBJECTIVE: Obsessive-compulsive disorder is characterized by a chronic course that can vary between patients. The knowledge on the naturalistic long-term outcome of obsessive-compulsive disorder and its predictors is surprisingly limited. The present research was designed to identify clinical and psychosocial predictors of the long-term outcome of obsessive-compulsive disorder. METHODS: We included 377 individuals with a current diagnosis of obsessive-compulsive disorder, who participated in the Netherlands Obsessive Compulsive Disorder Association study, a multicenter naturalistic cohort study. Predictors were measured at baseline using self-report questionnaires and clinical interviews. Outcome was assessed using the Yale-Brown Obsessive Compulsive Scale at 2-, 4- and 6-year follow-up. RESULTS: The overall course of obsessive-compulsive disorder was characterized by two prominent trends: the first reflected an improvement in symptom severity, which was mitigated by the second, worsening trend in the long term. Several determinants affected the course variations of obsessive-compulsive disorder, namely, increased baseline symptom severity, late age of onset, history of childhood trauma and autism traits. CONCLUSION: The long-term outcome of obsessive-compulsive disorder in naturalistic settings was characterized by an overall improvement in symptom severity, which was gradually halted to the point of increased worsening. However, after 6 years, the severity of symptoms remained below the baseline level. While certain determinants predicted a more favorable course, their effect diminished over time in correspondence to the general worsening trend. The results highlight the importance of a regular and continuous monitoring for symptom exacerbations as part of the management of the obsessive-compulsive disorder, regardless of the presence of putative predictors.

Waxing and waning: The roles of chronotype and time of day in predicting symptom fluctuations in obsessive-compulsive disorder using a daily-monitoring design.

Obsessive-compulsive disorder (OCD) symptoms fluctuate throughout the day, but scientists are not sure what underlies these fluctuations. One factor which may explain how OCD symptoms wax and wane throughout the day is alertness. Increased alertness is associated with greater inhibitory control, a factor which plays a significant role in patients' ability to overcome their OCD symptoms. The current study examined the relationship between chronotype (morningness/eveningness preference, a measure of alertness) and within-day OCD symptom severity fluctuations. We hypothesized that increased alertness leads to better inhibitory abilities and, therefore, reduced OCD symptoms. OCD Symptoms were measured through 7-days of monitoring in which participants were asked to retrospectively rate their symptoms at several timepoints throughout the day. Chronotype was measured using the Morningness/Eveningness Questionnaire (MEQ). Consistent with our hypotheses, results revealed an interaction between chronotype and time of day, such that those with an eveningness preference tended to have worse symptoms in the morning, and vice versa. In addition, we also report novel findings regarding the effect of bedtime, sleep duration, and sleep quality on symptom severity the next day. Taken together, these findings suggest that alertness may modulate OCD symptom severity throughout the day such that individuals experience more severe symptoms during times of low alertness. The clinical and theoretical implications of these findings are discussed.

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.

The correlates of social phobia in OCD: Findings from a large clinical sample.

OBJECTIVES: Obsessive-compulsive disorder (OCD) is a debilitating psychiatric disorder, often complicated with comorbidities. Social phobia (SP) is the most frequent co-occurring anxiety disorder in OCD, associated with increased clinical severity. However, no study had examined the relevance of interpersonal processes in this comorbidity, which are at the core of SP. This study characterized the clinical (i.e., symptom profile, age of onset, chronicity, and comorbidity), vulnerability (i.e., childhood trauma, negative life events), and interpersonal (attachment style, expressed emotion, and social support) correlates of comorbid SP in a large sample of OCD patients. METHODS: We analysed the data of 382 OCD patients participating in the Netherlands Obsessive Compulsive Disorder Association (NOCDA) study. We examined the correlates of SP in OCD using self-report questionnaires and structured clinical interviews. In addition, data of 312 non-OCD SP patients were drawn from the Netherlands Study of Depression and Anxiety (NESDA), to compare the age of onset of SP between groups. Descriptive univariate analyses were followed by backward stepwise logistic regression analyses. RESULTS: Social phobia was present among approximately 20% of OCD patients. Social phobia in OCD was associated with increased depression severity and decreased ratings of secure attachment style. Among OCD patients, SP had a significantly earlier age onset as compared to SP in non-OCD patients. CONCLUSION: Social phobia in OCD might render a vulnerable clinical picture, characterized with early onset of SP symptoms, insecure attachment style, and increased depressive symptoms. Future studies should use prospective designs to better understand the nature of comorbid SP in OCD. PRACTITIONER POINTS: Approximately one fifth of OCD patients were diagnosed with comorbid social phobia in a large representative clinical sample. OCD patients with comorbid social phobia presented with a vulnerable clinical picture, characterized with increased depression severity and decreased ratings of secure attachment style. Social phobia in OCD was associated with an earlier AOO as compared to the AOO of social phobia without OCD. The findings are limited by a cross-sectional design; thus, causality could not be assessed. Research is needed to further examine the mechanisms of comorbid social phobia in OCD.

Momentary Induction of Inhibitory Control and Its Effects on Uncertainty.

Deficient inhibitory control and difficulty resolving uncertainty are central in psychopathology. How these factors interact remains unclear. Initial evidence suggests that inducing inhibitory control improves resolution of uncertainty. This may occur only when participants overcome action tendencies, which are dominant tendencies to perform certain behaviors. Our study explored the links between inhibitory control and behavioral responses to uncertainty while manipulating action-tendencies' strength. In three experiments, 132 undergraduates completed a task that combined induction of momentary changes in inhibitory control level (Stroop task), with responses to uncertainty (visual-search task). We manipulated action-tendencies' strength by varying uncertainty proportions across experiments. Results indicated that momentary induction of inhibitory control improved resolution of high-uncertainty during mostly low-uncertainty trials but hampered resolution of low-uncertainty during mostly high-uncertainty trials. Identical inhibitory control induction did not affect resolution of uncertainty when uncertainty conditions were equalized. Participants' subjective uncertainty measures were similar across experiments. Our results suggest that momentary inhibitory control induction modifies behavioral responses to uncertainty and selectively affects trials that require overcoming dominant action tendencies. These findings indicate a potentially unique and multifaceted relationship between inhibitory control and behavioral responses to uncertainty. Clinical implications for models of Obsessive-Compulsive Disorder and experimental implications to post-conflict processes are discussed.

Childhood trauma and attachment style predict the four-year course of obsessive compulsive disorder: Findings from the Netherlands obsessive compulsive disorder study.

INTRODUCTION: Obsessive compulsive disorder (OCD) is a chronic psychiatric disorder where most patients do not reach full symptomatic remission. Identifying predictors of course can improve patients' care by informing clinicians on prognosis and enhancing treatment strategies. Several predictors associated with improved outcome of OCD were identified. However, research focused mainly on clinical, illness-related predictors of the course of OCD. This study examined the contribution of environmental and interpersonal predictors on the long-term outcome of OCD, in addition to the previously identified clinical indicators. METHODS: We used the baseline, two and four-year data of 382 adult OCD patients participating in the naturalistic cohort study of the Netherlands Obsessive Compulsive Disorder Association (NOCDA). Remission was assessed using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). Predictors of outcome were assessed at baseline, via clinician-rated and self-report instruments. RESULTS: Remission at two and at four-year follow-up ranged from 11% to 26%. Early age of onset and the presence of childhood trauma predicted a worse four-year course. Secure attachment style emerged as a protective predictor of improved outcome. LIMITATIONS: The naturalistic design of our study did not enable a systematic estimation the effect of treatments received during the follow-up period. Furthermore, age of onset and childhood trauma were assessed retrospectively, which may contribute to recall bias. CONCLUSION: Results coincide with previous prediction research and stress the importance of adaptive interpersonal functioning in the course of OCD. Clinical implications and future research directions are discussed.

Predictors of treatment outcome in OCD: An interpersonal perspective.

Although effective treatments for obsessive compulsive disorder (OCD) are increasingly available, a considerable percentage of patients fails to respond or relapses. Predictors associated with improved outcome of OCD were identified. However, information on interpersonal determinants is lacking. This study investigated the contribution of attachment style and expressed emotion to the outcome of exposure and response prevention (ERP), while accounting for previously documented intrapersonal (i.e., symptom severity and personality pathology) predictors. Using logistic regression analyses and multi-level modeling, we examined predictors of treatment completion and outcome among 118 adult OCD patients who entered ERP. We assessed outcome at post treatment, and at four and 13 months from treatment completion. OCD baseline severity and fearful attachment style emerged as the main moderators of treatment outcome. Severe and fearfully attached patients were more likely to dropout prematurely. The improvement of fearful clients was attenuated throughout treatment and follow-up compared to non-fearful clients. However, their symptom worsening at the long-term was also mitigated. Severe OCD patients had a more rapid symptom reduction during treatment and at follow-up, compared to less severe clients. The findings suggest that both baseline OCD severity and fearful attachment style play a role in the long-term outcome of ERP.

Regulating Obsessive-Like Thoughts: Comparison of Two Forms of Affective Labeling with Exposure Only in Participants with High Obsessive-Compulsive Symptoms.

OBJECTIVE: A growing body of research has shown that mere expression of affective words (affect labeling) can help dampen emotional responses, as reflected by these words. Previous studies revealed that affect labeling can reduce physiological anxiety responses of subjects suffering from anxiety disorders. In addition, multiple studies have shown that obsessive-compulsive disorder (OCD) individuals have difficulty understanding their own emotions. However, the effect of affect labeling is unknown for people with high- OC symptoms. METHOD: We used different forms of affect labeling (emotion generation vs. emotion categorization) to examine their effect on participants with high-OC symptoms, and to find if these forms can be learned and generalized. Using a mix-model design, we compared the effects of emotion generation labeling, emotion categorization labeling, and exposure alone during exposure to distressing obsessive thoughts, at two different times, using both physiological and self-reported fear measures. RESULTS: At the first session, the emotion categorization group exhibited reduced fear physiological responses, compared to the other groups; however, it did not differ from the other groups in self-reported fear responses. At the second session, all groups revealed reduced physiological and self-reported fear responses, suggesting that affect labeling was neither learned nor generalized. CONCLUSIONS: Our findings suggest that affect labeling may help attenuate physiological anxiety responses in high-OC subjects. Furthermore, they suggest different effects for the different affect labeling forms. Future research exposing participants for longer durations may further elucidate the role of labeling in facilitating exposure effects.

Body mass index in obsessive-compulsive disorder.

BACKGROUND: Psychiatric disorders are associated with overweight/obesity. Obsessive-compulsive disorder (OCD) may be an exception, as anecdotal evidence suggests lower BMI in OCD. Additionally, depression is associated with elevated BMI, but effects of comorbid secondary depression are unknown. The aim of the present study was to assess BMI and risk for overweight/obesity in OCD and to assess the effect of comorbid depression on BMI. METHODS: BMI, demographics, and clinical status were assessed in large samples of individuals with OCD, anxiety disorders, depressive disorders, comorbid anxiety/depressive disorders, and non-clinical controls (NCC). RESULTS: Although no initial differences were found between the samples on BMI, the non-depressed OCD subsample had significantly lower BMI and risk for overweight/obesity compared to all other clinical samples. NCC were nearly twice as likely to be overweight compared to non-depressed OCD. LIMITATIONS: Eating disorders were excluded in the OCD sample, but BMI < 17 was used as an exclusion criterion in the clinical control groups in lieu of screening for Anorexia. Group differences on demographics were controlled for. Recruitment methodology differed between samples. CONCLUSIONS: OCD is associated with significantly lower rates of obesity and overweight, but this relationship was not found when comorbid depression was present. This suggests that the purer the phenotype of OCD, the more substantial protective factor against overweight/obesity emerges compared to other clinical samples and NCC. An OCD-specific reward/anhedonia model, previously offered to elucidate lower smoking rates in OCD, may account for lower BMI in OCD. These results warrant careful clinical attention to the negative impact of comorbid depression on OCD that spans from increasing risk for obesity and cigarette smoking, to hindering treatment response.

The relationship between cognitions and symptoms in obsessive-compulsive disorder.

BACKGROUND: The cognitive theory of obsessive-compulsive disorder (OCD) ascertains that catastrophic (mis)interpretations of normally occurring intrusive thoughts are related to the maintenance of OCD. Nonetheless, findings supporting the relationship between cognitive biases and OCD symptoms are largely inconsistent. In the present study we examined the relationship between OCD cognitions and symptoms among 382 OCD patients participating in the longitudinal Netherlands Obsessive Compulsive Disorder Association (NOCDA) study. METHODS: OCD cognitions and OC, anxiety and depressive symptoms were assessed using self-report questionnaires at baseline and at two-year follow-up. Baseline multiple regression analyses assessed the specificity of OC cognitions to OCD symptoms. Cross-lagged analyses examined whether cognitions predict OCD symptoms at two-year follow up. RESULTS: Baseline analyses demonstrated significant relationships between comorbid anxiety, depressive severity and OC cognitions, adjusted for OCD symptoms (ß = .283, p < .001 and ß = .246, p < .001, respectively). OCD severity adjusted for comorbid symptoms was unrelated to cognitions at baseline (ß = .040, p = n.s). Unique associations were found between cognitions and two OCD symptom subtypes (Impulses: ß = .215, p < .001; Rumination/doubting: ß = .205, p < .001). Longitudinal analyses yielded non-significant associations between OCD cognitions and symptom severity. Prospective analyses of cognitions and OCD symptom subtypes yielded significant effects for both bidirectional and unidirectional associations (ß = .11-.16, p < .05). LIMITATIONS: Given the naturalistic design of the study, we did not assess therapeutic interventions between baseline and follow-up. CONCLUSIONS: Results only partially concord with the predictions of the cognitive theory of OCD. Future studies should focus on mechanisms alternative to cognitions when investigating the course of OCD.

Categorized Affective Pictures Database (CAP-D).

Emotional picture databases are commonly used in emotion research. The databases were first based on ratings of emotional dimensions, and the interest in studying discrete emotions led to the categorization of subsets from these databases to emotional categories. However, to-date, studies that categorized affective pictures used confidence intervals in their analysis, a method that provides important data but also results in a high percentage of blended or undifferentiated categorization of images. The current study used 526 affective pictures from four databases and categorized the pictures to discrete emotions in two steps (Pre-testing phase & Experiment 1). First, clinical psychologists were asked to generate emotional labels for each picture, according to the emotion the picture evoked in them. This resulted in the creation of 10 emotional categories. These labels were presented to students who were asked to choose the emotional category that matched the emotion a presented picture evoked in them. Agreement levels on the emotional categories were calculated for each picture, and pictures were categorized according to the most dominant emotion they evoked. The analysis of agreement levels rather than confidence intervals enabled us to provide both dominance of emotional category and agreement in the population regarding the dominance. In Experiment 2, we asked participants to provide ratings of emotional intensity and arousal, in order to provide more detailed information regarding the database. This is the first study to provide agreement levels on the categorization of affective pictures, and may be useful in various studies which aim at generating specific emotions.

To Do or Not to Do? Task Control Deficit in Obsessive-Compulsive Disorder.

Task control is an executive control mechanism that facilitates goal-directed task selection by suppressing irrelevant automatic "stimulus-driven" behaviors. In the current study, we test the hypothesis that less efficient task control in individuals diagnosed with obsessive-compulsive disorder (OCD) is associated with OCD symptoms, and specifically, with the inability to inhibit unwanted behaviors in OCD. Thirty-five healthy controls, 30 participants with OCD, and 26 participants with generalized anxiety disorder (GAD) completed the object-interference (OI) task to measure task control, the stop-signal task to measure response inhibition, and the arrow-flanker task to evaluate executive abilities not contingent upon task control. OCD patients, but not GAD patients or healthy controls, exhibited impaired performance on the OI task. The deficit in task control, but not in response inhibition, correlated with OCD symptom severity. We suggest that reduced task control may be one of the neurocognitive processes that underlie the inability to inhibit unwanted behaviors in OCD.

Examining procedural working memory processing in obsessive-compulsive disorder.

Previous research has suggested that a deficit in working memory might underlie the difficulty of obsessive-compulsive disorder (OCD) patients to control their thoughts and actions. However, a recent meta-analyses found only small effect sizes for working memory deficits in OCD. Recently, a distinction has been made between declarative and procedural working memory. Working memory in OCD was tested mostly using declarative measurements. However, OCD symptoms typically concerns actions, making procedural working-memory more relevant. Here, we tested the operation of procedural working memory in OCD. Participants with OCD and healthy controls performed a battery of choice reaction tasks under high and low procedural working memory demands. Reaction-times (RT) were estimated using ex-Gaussian distribution fitting, revealing no group differences in the size of the RT distribution tail (i.e., τ parameter), known to be sensitive to procedural working memory manipulations. Group differences, unrelated to working memory manipulations, were found in the leading-edge of the RT distribution and analyzed using a two-stage evidence accumulation model. Modeling results suggested that perceptual difficulties might underlie the current group differences. In conclusion, our results suggest that procedural working-memory processing is most likely intact in OCD, and raise a novel, yet untested assumption regarding perceptual deficits in OCD.

The Role of Response Inhibition in Medicated and Unmedicated Obsessive-Compulsive Disorder Patients: Evidence from the Stop-Signal Task.

BACKGROUND: Numerous studies have investigated response inhibition (RI) in obsessive-compulsive disorder (OCD), with many reporting that OCD patients demonstrate deficits in RI as compared to controls. However, reported effect sizes tend to be modest and results have been inconsistent, with some studies finding intact RI in OCD. To date, no study has examined the effect of medications on RI in OCD patients. METHODS: We analyzed results from a stop-signal task to probe RI in 65 OCD patients (32 of whom were medicated) and 58 healthy controls (HCs). RESULTS: There was no statistically significant difference in stop-signal reaction time between the OCD group and the HC group, or between the medicated and unmedicated OCD patients. However, variability was significantly greater in the medicated OCD group compared to the unmedicated group. CONCLUSIONS: These results indicate that some samples of OCD patients do not have deficits in RI, making it unlikely that deficient RI underlies repetitive behaviors in all OCD patients. Future research is needed to fully elucidate the impact of medication use on stop-signal performance. Implications for future research on the cognitive processes underlying repetitive thoughts and behaviors are discussed.

Inhibiting uncertainty: Priming inhibition promotes reduction of uncertainty.

Uncertainty affects performance in many cognitive tasks, including the visual-search task, and individual differences in the experience of uncertainty may contribute to several psychological disorders. Despite the importance of uncertainty, to date, no study has explained the basic mechanisms underlying individual differences in the experience of uncertainty. However, it has been suggested that inhibition, a cognitive mechanism aimed at suppressing unwanted thoughts or actions, may affect the development of uncertainty. In the current study, we investigated the relationship between inhibition and behavioral responses to uncertainty in the visual-search task. To accomplish this goal, forty six university students completed a novel combined visual-search and stop-signal task, in which we manipulated the degree to which the inhibitory control system was activated by varying the proportions of stop signals in separate blocks. We utilized target-absent trials in the visual-search task as a behavioral probe of responses to uncertainty. We found that activating higher levels of inhibitory control resulted in faster responses to target-absent visual-search trials, while not affecting target-present trials. These findings suggest that activation of inhibitory control may causally affect behavioral responses to uncertainty. Thus, individual differences in inhibitory control may influence the ability to rely on internal-ambiguous cues which are common in visual-search and other cognitive tasks. Clinical implications for obsessive-compulsive disorder (OCD) and other disorders involving deficient inhibitory control and difficulty with uncertainty are discussed.