Adding acceptance and commitment therapy to exposure and response prevention for obsessive-compulsive disorder: A randomized controlled trial.

The objective of this study was to test whether treatment acceptability, exposure engagement, and completion rates could be increased by integrating acceptance and commitment therapy (ACT) with traditional exposure and response prevention (ERP). 58 adults (68% female) diagnosed with obsessive-compulsive disorder (OCD; M age = 27, 80% white) engaged in a multisite randomized controlled trial of 16 individual twice-weekly sessions of either ERP or ACT + ERP. Assessors unaware of treatment condition administered assessments of OCD, depression, psychological flexibility, and obsessional beliefs at pretreatment, posttreatment, and six-month follow-up. Treatment acceptability, credibility/expectancy, and exposure engagement were also assessed. Exposure engagement was high in both conditions and there were no significant differences in exposure engagement, treatment acceptability, or dropout rates between ACT + ERP and ERP. OCD symptoms, depression, psychological inflexibility, and obsessional beliefs decreased significantly at posttreatment and were maintained at follow-up in both conditions. No between-group differences in outcome were observed using intent to treat and predicted data from multilevel modeling. ACT + ERP and ERP were both highly effective treatments for OCD, and no differences were found in outcomes, processes of change, acceptability, or exposure engagement.

Uncertainty as an anxiety cue at high and low levels of threat.

BACKGROUND AND OBJECTIVES: Intolerance of uncertainty and the overestimation of threat contribute to the maintenance of anxiety; however, the interaction between uncertainty and threat perception has not been examined empirically. The current study examined the extent to which explicitness of uncertainty is involved in perceptions of, and responses to, scenarios about threatening situations. METHODS: A series of systematically varied scenarios were used to examine whether manipulating uncertainty (implicit vs. explicit) and threat level (high vs. low) altered the perception of a situation as anxiety-inducing. Undergraduate participants (n = 373) responded to vignettes about common situations (e.g., taking an elevator) with ratings of anxiety and desire to perform a safety behavior. RESULTS: Results revealed that higher threat situations, and those in which uncertainty was made explicit, provoked higher ratings of anxiety and urge to perform a safety behavior. In addition, explicit uncertainty significantly increased anxiety and urge to perform a safety behavior at low, but not at high, levels of threat. LIMITATIONS: Participants rated (via self-report) their hypothetical feelings as induced by vignettes, rather than actually experiencing these situations in vivo. CONCLUSIONS: We found evidence for "uncertainty-based reasoning," in which an individual perceives a situation as more anxiety-provoking (and is more likely to have the urge to perform a safety behavior) when the uncertain aspects of a situation are obvious or explicit, than when such uncertainty is merely implied or tacit. Implications for the understanding of "uncertainty-based reasoning" are discussed.

How is the Beads Task related to intolerance of uncertainty in anxiety disorders?

Intolerance of uncertainty (IU) is a cognitive bias associated with anxiety disorders that has only been reliably measured using self-report instruments. The current study investigated relationships between a probabilistic inference task - the Beads Task - and self-report IU. Individuals with anxiety disorders (ANX) and non-anxious controls (NAC) completed self-report measures as well as the Beads Task at three levels of difficulty. The Beads Task successfully induced task-related uncertainty as the decision became more difficult. While the two groups did not differ on the observable performance related measures, the ANX group was significantly more distressed during the task than were the NACs. Moreover, among the ANX group, self-reported IU was correlated with draws to decision and distress during the task. The Beads Task appears to provoke distress associated with uncertainty for anxious individuals, rather than altering their behavioral responses; thus, clinical implications and avenues for future research are discussed.

The relevance of analogue studies for understanding obsessions and compulsions.

Analogue samples are often used to study obsessive-compulsive (OC) symptoms and related phenomena. This approach is based on the hypothesis that results derived from such samples are relevant to understanding OC symptoms in individuals with a diagnosis of obsessive-compulsive disorder (OCD). Two decades ago, Gibbs (1996) reviewed the available literature and found initial support for this hypothesis. Since then there have been many important advances addressing this issue. The purpose of the present review was to synthesize various lines of research examining the assumptions of using analogue samples to draw inferences about people with OCD. We reviewed research on the prevalence of OC symptoms in non-clinical populations, the dimensional (vs. categorical) nature of these symptoms, phenomenology, etiology, and studies on developmental and maintenance factors in clinical and analogue samples. We also considered the relevance of analogue samples in OCD treatment research. The available evidence suggests research with analogue samples is highly relevant for understanding OC symptoms. Guidelines for the appropriate use of analogue designs and samples are suggested.

Just to be certain: Confirming the factor structure of the intolerance of uncertainty scale in patients with obsessive-compulsive disorder.

Intolerance of uncertainty (IU) is a cognitive construct in obsessive-compulsive disorder (OCD); yet no studies exist confirming the factor structure of the most widely used measure of IU, the intolerance of uncertainty scale (IUS), in OCD patients. Moreover, no studies have examined how scores on this measure relate to OCD symptom dimensions. Accordingly, the present study examined a 12-item two-factor revised version of the IUS (IUS-12) in 205 OCD patients. Confirmatory factor analysis verified the scale's two-factor structure. The measure also demonstrated high internal consistency and the IUS-12 was correlated moderately with another self-report measure of IU. Finally, theoretically consistent and specific relationships emerged between the IUS-12 and OCD symptom dimensions. These findings are discussed in terms of implications for the assessment and treatment of OCD, and specifically how elevated scores on the IUS-12 subscales may be utilized to identify subtleties in the presentation of OCD-related problems with IU.

Treating obsessive-compulsive disorder in intimate relationships: a pilot study of couple-based cognitive-behavior therapy.

Although cognitive-behavioral therapy (CBT) involving exposure and response prevention (ERP) is an established treatment for obsessive-compulsive disorder (OCD), not all patients respond optimally, and some show relapse upon discontinuation. Research suggests that for OCD patients in close relationships, targeting relationship dynamics enhances the effects of CBT. In the present study, we developed and pilot tested a 16-session couple-based CBT program for patients with OCD and their romantic partners. This program included (a) partner-assisted ERP, (b) techniques targeting maladaptive relationship patterns focal to OCD (e.g., symptom accommodation), and (c) techniques targeting non OCD-related relationship stressors. OCD, related symptoms, and relationship functioning were assessed at baseline, immediately following treatment (posttest), and at 6- and 12-month follow-up. At posttest, substantial improvements in OCD symptoms, relationship functioning, and depression were observed. Improvements in OCD symptoms were maintained up to 1year. Results are compared to findings from studies of individual CBT for OCD and discussed in terms of the importance of addressing interpersonal processes that maintain OCD symptoms.

Let me check that for you: symptom accommodation in romantic partners of adults with Obsessive-Compulsive Disorder.

Obsessive Compulsive Disorder (OCD) is typically considered from the perspective of the individual, yet symptoms often occur within an interpersonal context. Family members often engage in accommodation, assisting patients with rituals in order to alleviate anxiety, prevent conflict, or "help out" with time-consuming compulsive behaviors. Prior research has primarily examined accommodation in parents of children with OCD or in adult caregiver relationships, where caregivers can include various family members (e.g., parents, romantic partners). The current study examined accommodation behaviors in romantic partners of adults with OCD. As part of a treatment study, 20 couples were assessed for accommodation behaviors, OCD symptoms, and relationship functioning before and after 16-sessions of cognitive-behavioral treatment. Accommodation was associated with the patient's OCD symptoms at pre-treatment, and negatively associated with the partners', but not the patients', self-reported relationship satisfaction. Post-treatment partner accommodation was also associated with poorer response to treatment. The implications of these findings are discussed within an interpersonal framework, and the benefits of including partners in the treatment of OCD are described.

Enhancing exposure and response prevention for OCD: a couple-based approach.

The effectiveness of individual therapy by exposure and response prevention (ERP) for obsessive-compulsive disorder (OCD) is well established, yet not all patients respond well, and some show relapse on discontinuation. This article begins by providing an overview of the personal and interpersonal experiences of OCD, focusing on interpersonal processes that maintain OCD symptoms and interfere with ERP. The study then describes a couple-based treatment program that the authors have developed to enhance ERP for individuals with OCD who are in long-term relationships. This program involves psychoeducation, partner-assisted exposure therapy, couple-based interventions aimed at changing maladaptive relationship patterns regarding OCD (i.e., symptom accommodation), and general couple therapy. Three case examples are presented to illustrate the couple-based techniques used in this treatment program.

The contribution of experiential avoidance and social cognitions in the prediction of social anxiety.

BACKGROUND: Cognitive models propose that social anxiety arises from specific dysfunctional cognitions about the likelihood and severity of embarrassment. Relational frame theory (RFT), on the other hand, posits that social anxiety arises from the unwillingness to endure unpleasant internal experiences (i.e. experiential avoidance [EA]). Although cognitive models have garnered empirical support, it may be that newer models such as RFT can improve our ability to predict and treat social anxiety. AIMS: We aimed to elucidate the relationship between dysfunctional cognitions and EA, as well as their independent and relative contributions to the prediction of social anxiety symptoms. We hypothesized that dysfunctional cognitions and EA would each be associated with social anxiety, as well as with each other. We also predicted that both EA and dysfunctional cognitions would remain independent predictors of social anxiety symptoms after controlling for each other and general distress. METHOD: Undergraduates high (n = 173) and low (n = 233) in social anxiety completed measures of social anxiety, dysfunctional cognitions, EA, and general distress. The overall sample was 66.3% female; mean age = 20.01 years (SD = 2.06). RESULTS: Correlational analyses revealed that EA, dysfunctional cognitions, and social anxiety symptoms were moderately correlated with one another. Additionally, hierarchical regression analyses revealed that dysfunctional cognitions predicted social anxiety symptoms even after controlling for EA; the reverse was not found. CONCLUSIONS: RESULTS suggest that EA and social anxiety specific cognitive distortions overlap to a moderate extent. EA does not add to the prediction of social anxiety symptoms above and beyond dysfunctional cognitions. Additional theoretical and treatment implications of the results are discussed.

Differences in obsessive-compulsive symptoms and obsessive beliefs: a comparison between African Americans, Asian Americans, Latino Americans, and European Americans.

Clinical research has increasingly considered ethnic group differences in the expression of anxiety disorders, but to date few investigations have focused specifically on the symptoms of obsessive-compulsive disorder (OCD). We examined group differences in OC symptoms, related cognitions ("obsessive beliefs"), and their associations. The sample included European American (N = 1199), African American (N = 215), Asian American (N = 116), and Latino American (N = 72) participants. African American and Asian American participants reported more contamination-related OC symptoms than did European Americans. Asian Americans also reported elevated levels of obsessive beliefs. Moreover, group membership moderated the relationship between obsessive beliefs and certain dimensions of OC symptoms. These findings suggest group differences in the experience of OC symptoms and related cognitions, and that the cognitive-behavioral model of some OC symptoms could be refined and tailored for groups underrepresented in OCD research to date.

A Comparison of Two Brief Interventions for Obsessional Thoughts: Exposure and Acceptance.

Exposure and response prevention (ERP) is the most effective psychological treatment for unwanted, intrusive thoughts associated with obsessive-compulsive disorder (OCD). However, the procedures involved in ERP (i.e., exposure) are challenging, provoke high levels of anxiety, and may contribute to treatment refusal and dropout (Franklin & Foa, 1998). To address this problem, researchers have begun to evaluate alternative treatments for OCD, such as Acceptance and Commitment Therapy (ACT). Despite the value of both techniques, little is known about the differential impact of these strategies. This study examined the relative effects of a single session of ACT or exposure for obsessional thoughts. There were 56 undergraduate participants with obsessional thoughts randomly assigned to receive a brief intervention with the core components of exposure, ACT, or an expressive writing control condition. Obsessional symptoms and related process variables were assessed at baseline and at 1-week follow-up. There were no statistical differences in believability or acceptability of the 3 conditions. Significant reductions in obsessional severity, behavioral tests of distress and willingness to experience intrusive thoughts, and negative appraisals of intrusive thoughts occurred in all conditions, but no differences were found between these conditions. Furthermore, changes in dysfunctional beliefs, but not in willingness to experience intrusive thoughts, predicted changes in obsessional symptoms in both the ACT and exposure conditions.

The effects of familiarity on thought--action fusion.

The present study examined whether beliefs about the importance of thoughts (i.e., thought--action fusion; TAF) are related to the target subject of the negative thought. One hundred and seven undergraduate students were randomly assigned to imagine either a beloved relative or a stranger being diagnosed with cancer and provided in vivo ratings of anxiety, likelihood, moral wrongness, urge to neutralize, and how upsetting the event would be if it occurred. Results indicated that thinking of a relative being diagnosed with cancer provoked more distress, urges to neutralize, and higher estimates of likelihood, as well greater use of mental neutralizing behaviors, compared to thinking of a stranger. Contrary to our prediction, the groups did not differ in their ratings of the moral wrongness. These findings broadly support the assertion that the more personally significant a negative intrusive thought, the more it will provoke distress and urges to neutralize. Results are discussed in terms of the cognitive model of obsessions and clinical implications are addressed.