Neurocognitive performance in the context of acute symptom reduction in OCD: Treatment effects and the impact of BDNF.

BACKGROUND: Obsessive-compulsive disorder (OCD) has been associated with neurocognitive impairments. The present study examined the effect of treatment on neurocognitive performance in OCD and the relationship between neurocognitive change and symptom change. The present study also examined polymorphisms influencing brain derived neurotrophic factor (BDNF) as predictors of neurocognitive change. METHOD: Treatment-seeking participants with OCD (N = 125) were assigned to cognitive behavioural therapy (CBT) alone, CBT combined with regular physical exercise, exercise alone, or a waitlist control group. Measures of OCD symptom severity and a neuropsychological battery were completed pre- and post-treatment. Blood or saliva samples were used to genotype the BDNF Val66Met polymorphism. RESULTS: OCD symptom severity was not cross-sectionally associated with neurocognitive performance. Several neurocognitive measures improved over treatment. The BDNF Val66Met polymorphism was significantly associated with worse performance on the Stroop test but did not significantly predict change in neurocognitive performance over time. LIMITATIONS: Limitations include lack of a healthy control group. CONCLUSION: Improvement in neurocognitive performance corresponded to symptomatic improvement and was independent of the BDNF Val66Met genotype.

The Use of Text Messaging as an Adjunct to Internet-Based Cognitive Behavioral Therapy for Major Depressive Disorder in Youth: Secondary Analysis.

BACKGROUND: As an established treatment for major depressive disorder (MDD), cognitive behavioral therapy (CBT) is now implemented and assessed in internet-based formats that, when combined with smartphone apps, enable secure text messaging. As an adjunct to such internet-based CBT (ICBT) approaches, text messaging has been associated with increased adherence and therapeutic alliance. OBJECTIVE: This study analyzed data from the intervention arm of a randomized control trial evaluating 24-week ICBT for MDD (intervention arm) against standard-care psychiatry (waitlist control). The aim of this secondary analysis was to assess MDD symptom improvement in relation to the frequency and content of text messages sent by ICBT participants to Navigator-Coaches during randomized control trial participation. Higher text frequency in general and in 3 conceptual categories (appreciating alliance, alliance building disclosures, and agreement confirmation) was hypothesized to predict larger MDD symptom improvement. METHODS: Participants were young adults (18-30 years) from the Centre for Addiction and Mental Health. The frequencies of categorized texts from 20 ICBT completers were analyzed with respect to MDD symptom improvement using linear regression models. Texts were coded by 2 independent coders and categorized using content analysis. MDD symptoms were measured using the Beck Depression Inventory-II (BDI-II). RESULTS: Participants sent an average of 136 text messages. Analyses indicated that BDI-II improvement was negatively associated with text messaging frequency in general (ß=-0.029, 95% CI -0.11 to 0.048) and in each of the 3 categories: appreciating alliance (ß=-0.096, 95% CI -0.80 to 0.61), alliance building disclosures (ß=-0.098, 95% CI -0.28 to 0.084), and agreement confirmation (ß=-0.076, 95% CI -0.40 to 0.25). Altogether, the effect of text messaging on BDI-II improvement was uniformly negative across statistical models. More text messaging appeared associated with less MDD symptom improvement. CONCLUSIONS: The hypothesized positive associations between conceptually categorized text messages and MDD symptom improvement were not supported in this study. Instead, more text messaging appeared to indicate less treatment benefit. Future studies with larger samples are needed to discern the optimal use of text messaging in ICBT approaches using adjunctive modes of communication. TRIAL REGISTRATION: Clinical Trials.gov NCT03406052; https://www.clinicaltrials.gov/ct2/show/NCT03406052.

A Rapid Access Brief Psychotherapy Intervention to Respond to Healthcare Workers in Ontario Whose Mental Health was Negatively Impacted During the COVID-19 Pandemic.

OBJECTIVE: Although the coronavirus disease 2019 (COVID-19) pandemic has had widespread negative impacts on the mental health of healthcare workers (HCWs), there has been little research on psychological interventions during the pandemic for this population. The current study examines whether a brief coping-focused treatment intervention delivered in a virtual individual format would be associated with positive changes in Canadian HCWs' mental health during the pandemic. METHOD: Three hundred and thirty-three HCWs receiving the intervention at 3 large specialty tertiary care hospitals in Ontario, Canada, completed measures of anxiety, depression, perceived stress, work/social impairment, insomnia and fear of COVID-19. After completing treatment, HCWs rated their satisfaction with the treatment. RESULTS: The intervention was associated with large effect size improvements in anxiety, depression, perceived stress, insomnia and fear of COVID-19, and moderate effect size improvements in work/social impairment. At treatment session 1, prior mental health diagnosis and treatment were both significantly correlated with depression, anxiety, and work/social impairment scores. Secondary analyses of data from one of the sites revealed that treatment-related changes in anxiety, depression, perceived stress and work/social impairment were independent of age, gender, occupational setting, profession and the presence of a previous mental health diagnosis or treatment, with the exception that nurses improved at a slightly greater rate than other professions in terms of work/social impairment. HCWs were highly satisfied with the treatment. CONCLUSIONS: A large number of HCWs experiencing significant distress at baseline self-referred for assistance. Timely and flexible access to a brief virtual coping-focused intervention was associated with improvements in symptoms and impairment, and treatment response was largely unrelated to demographic or professional characteristics. Short-term psychological interventions for HCWs during a pandemic may have a highly positive impact given their association with improvement in various aspects of HCWs' mental health improvement.

Toward personalized circuit-based closed-loop brain-interventions in psychiatry: using symptom provocation to extract EEG-markers of brain circuit activity.

Symptom provocation is a well-established component of psychiatric research and therapy. It is hypothesized that specific activation of those brain circuits involved in the symptomatic expression of a brain pathology makes the relevant neural substrate accessible as a target for therapeutic interventions. For example, in the treatment of obsessive-compulsive disorder (OCD), symptom provocation is an important part of psychotherapy and is also performed prior to therapeutic brain stimulation with transcranial magnetic stimulation (TMS). Here, we discuss the potential of symptom provocation to isolate neurophysiological biomarkers reflecting the fluctuating activity of relevant brain networks with the goal of subsequently using these markers as targets to guide therapy. We put forward a general experimental framework based on the rapid switching between psychiatric symptom states. This enable neurophysiological measures to be derived from EEG and/or TMS-evoked EEG measures of brain activity during both states. By subtracting the data recorded during the baseline state from that recorded during the provoked state, the resulting contrast would ideally isolate the specific neural circuits differentially activated during the expression of symptoms. A similar approach enables the design of effective classifiers of brain activity from EEG data in Brain-Computer Interfaces (BCI). To obtain reliable contrast data, psychiatric state switching needs to be achieved multiple times during a continuous recording so that slow changes of brain activity affect both conditions equally. This is achieved easily for conditions that can be controlled intentionally, such as motor imagery, attention, or memory retention. With regard to psychiatric symptoms, an increase can often be provoked effectively relatively easily, however, it can be difficult to reliably and rapidly return to a baseline state. Here, we review different approaches to return from a provoked state to a baseline state and how these may be applied to different symptoms occurring in different psychiatric disorders.

The effect of aerobic exercise alone and in combination with cognitive behavioural therapy on obsessive compulsive disorder: A randomized control study.

PURPOSE: Cognitive behavioural therapy (CBT) has been found to be an effective treatment for OCD, but there remains a significant proportion of individuals who fail to show a treatment response. Aerobic exercise has previously been associated with decreases in anxiety and depression, as well as improvements in OCD symptoms in small-scale studies. The purpose of the present research was to use a randomized control trial design to examine the effects of exercise alone and in combination with CBT, on OCD symptoms and secondary symptoms. METHOD: 125 participants were randomly assigned to one of four treatment groups: waitlist control, exercise, CBT, and CBT with exercise. OCD symptom severity was measured at four points over the course of treatment, secondary outcome measures were gathered at three points over treatment. RESULTS: CBT alone and combined with exercise was associated with significantly greater OCD symptom reduction than exercise alone or the control groups. Total exercise frequency predicted OCD symptom reduction in the groups in which exercise was measured. Group membership did not significantly predict reductions in secondary outcome measures. CONCLUSION: Exercise frequency, rather than the presence or absence of exercise, appears to predict OCD symptom reduction, as did participation in CBT.

Associations between rumination, depression, and distress tolerance during CBT treatment for depression in a tertiary care setting.

BACKGROUND: Rumination is strongly associated with depressive symptom severity and course. However, changes in rumination during outpatient cognitive behavioral therapy (CBT), and their links to baseline features such as distress tolerance and clinical outcomes, have received limited attention. METHODS: 278 outpatients with depression received group or individual CBT. Measures of rumination, distress tolerance, and depression symptom severity were assessed at baseline and periodically during treatment. Mixed effect and regression-based models evaluated changes over time, and associations between rumination, distress tolerance and depression severity. RESULTS: Depression and rumination decreased throughout acute treatment. Rumination reduction was concurrently associated with depressive symptom reduction. Lower levels of rumination at each time point prospectively predicted lower depressive symptoms at the next time point. Distress tolerance measured at baseline was positively associated with depression symptom severity; the indirect effect on post-treatment depression symptoms via rumination measured mid-treatment was nonsignificant when rumination at baseline was accounted for. Changes in and associations between depression and rumination were replicated in sensitivity analyses; although changes in depression and rumination were smaller in magnitude in patients receiving treatment during COVID-19. LIMITATIONS: Additional assessment points would permit a more nuanced assessment of the role rumination may play in mediating the associations between distress tolerance and depression severity. Additional investigation of treatments in community settings may also further our understanding of variability in rumination during depression treatment. CONCLUSIONS: The current study provides unique real-world support for variability in rumination as a key indicator of change over the course of CBT for depression.

The Impact of Group Feedback on Self-Perceptions Following Videotape Exposure in CBT for Social Anxiety Disorder.

Video feedback following social anxiety exposures improves self-perceptions. Clinical studies have not examined whether feedback from group members has incremental benefit beyond that of viewing the tape itself. Sixty-seven individuals with social anxiety disorder completed videotaped exposure during group based cognitive behavior therapy (CBT). After participants viewed their taped exposure, group members and therapists gave feedback. Participants completed ratings of anxiety and performance before and after taping their exposure, after viewing the video themselves, and after receiving group feedback. Appraisal of social concerns were assessed after taping, viewing, and group feedback. There were significant improvements in anxiety, performance, and decreased social concerns across time points. Comparing only the time points of after viewing and after receiving group feedback, the same pattern emerged for anxiety, performance, and appraisal of social concerns, with moderate to large effect sizes. Group feedback led to ratings that exceeded their own initial evaluation of their video. Video feedback in group CBT that also includes feedback from others may improve clinical outcomes.

Psychotherapies and digital interventions for OCD in adults: What do we know, what do we need still to explore?

BACKGROUND: Despite significant advances in the understanding and treatment of obsessive compulsive disorder (OCD), current treatment options are limited in terms of efficacy for symptom remission. Thus, assessing the potential role of iterative or alternate psychotherapies is important. Also, the potential role of digital technologies to enhance the accessibility of these therapies, should not be underestimated. We also need to embrace the idea of a more personalized treatment choice, being cognisant of clinical, genetic and neuroimaging predictors of treatment response. PROCEDURES: Non-systematic review of current literature on emerging psychological and digital therapies for OCD, as well as of potential biomarkers of treatment response. FINDINGS: A number of 'third wave' therapies (e.g., Acceptance and Commitment Therapy, Mindfulness-Based Cognitive Therapy) have an emerging and encouraging evidence base in OCD. Other approaches entail employment of elements of other psychotherapies such as Dialectical Behaviour Therapy; or trauma-focussed therapies such as Eye Movement Desensitisation and Reprocessing, and Imagery Rescripting and Narrative Therapy. Further strategies include Danger Ideation Reduction Therapy and Habit Reversal. For these latter approaches, large-scale randomised controlled trials are largely lacking, and the precise role of these therapies in treating people with OCD, remains to be clarified. A concentrated 4-day program (the Bergen program) has shown promising short- and long-term results. Exercise, music, and art therapy have not been adequately tested in people with OCD, but may have an adjunctive role. Digital technologies are being actively investigated for enhancing reach and efficacy of psychological therapies for OCD. Biomarkers, including genetic and neuroimaging, are starting to point to a future with more 'personalised medicine informed' treatment strategizing for OCD. CONCLUSIONS: There are a number of potential psychological options for the treatment of people with OCD who do not respond adequately to exposure/response prevention or cognitive behaviour therapy. Adjunctive exercise, music, and art therapy might be useful, albeit the evidence base for these is very small. Consideration should be given to different ways of delivering such interventions, including group-based, concentrated, inpatient, or with outreach, where appropriate. Digital technologies are an emerging field with a number of potential applications for aiding the treatment of OCD. Biomarkers for treatment response determination have much potential capacity and deserve further empirical testing.

Longitudinal changes in intolerance of uncertainty and worry severity during CBT for generalized anxiety disorder.

Intolerance of uncertainty (IU) is a key construct in generalized anxiety disorder (GAD), but little is known about the concurrent and temporal patterns of associations between IU and GAD symptom severity during treatment. In addition, most of the extant literature focuses on IU as a unidimensional construct, whereas some researchers conceptualize IU as being comprised of two dimensions, inhibitory and prospective IU. Ninety individuals with GAD completed measures of IU and worry severity at pre-treatment, session 4, session 8, and end of treatment (session 12), during group-based cognitive behavior therapy (CBT) for GAD. Longitudinal multilevel modeling showed that IU predicted worry severity concurrently, but not prospectively over time; this pattern of associations was found with the total IUS score and the inhibitory (but not prospective) subscale score. Further, the relationship between IU total scores and worry severity became stronger over time. The relationship between inhibitory (but not prospective) IU and worry also became stronger over time. When the order of the variables in the model was reversed, worry severity also predicted concurrent but not future IU. Therefore, change in IU is associated with change in worry throughout the course of CBT, particularly as treatment progresses, though its directional association as a cause and/or effect remains unclear.

Correction: Comparing Online and On-Site Cognitive Behavior Therapy in Major Depressive Disorder: Protocol for a Noninferiority Randomized Controlled Trial.

[This corrects the article DOI: 10.2196/29726.].

Social anxiety and negative interpretations of positive social events: What role does intolerance of uncertainty play?

OBJECTIVE: Although previous studies have demonstrated the association between social anxiety symptom severity and the tendency to appraise positive social events negatively among individuals with social anxiety disorder, no study has examined mediators of this relationship. The current study sought to examine whether intolerance of uncertainty and its subfactors mediate the relationship between social interaction anxiety and the tendency to interpret positive social events negatively. METHOD: One hundred and sixty-five individuals with social anxiety disorder completed measures of social interaction anxiety symptom severity, intolerance of uncertainty, and negative interpretations of positive social events. RESULTS: Total intolerance of uncertainty and the inhibitory-intolerance of uncertainty subscale scores significantly mediated the relationship between social interaction anxiety and negative interpretations of positive events. Exploratory post-hoc analyses regarding the possible contributing role of depression demonstrated mixed results. The same mediation pattern was found in the full sample as well as those without a secondary comorbid mood disorder diagnosis. In contrast, serial mediation showed a mediating role of depressive symptom severity. CONCLUSION: Inhibitory-intolerance of uncertainty plays a role in the relationship between social interaction anxiety and negative interpretations of positive social events.

Self-critical perfectionism, dependency and entropy during cognitive behavioural therapy for depression.

OBJECTIVES: This study examined whether 'personality vulnerability' (i.e., self-critical perfectionism or dependency) predicts the trajectory of change, as well as variability and instability (i.e., entropy) of symptoms, during cognitive behaviour therapy (CBT) for depression. DESIGN: Study participants were outpatients (N = 312) experiencing a primary mood disorder. Participants received CBT for depression group sessions over 15 weeks. Self-report measures of self-critical perfectionism, dependency, and depression were collected longitudinally. METHODS: A latent growth mixture modelling (LGMM) statistical approach was used to evaluate the presence of latent classes of individuals based on their longitudinal pattern of symptom change during CBT and to evaluate whether baseline self-critical perfectionism or dependency predicts class membership. A Latent Acceleration Score (LAS) model evaluated whether perfectionism or dependency led to variability in depression symptom change (e.g., velocity) by considering changes in velocity (e.g., acceleration and/or deceleration). RESULTS: LGMM indicated the presence of two latent classes that represent symptom improvement (N = 239) or minimal symptom improvement over time (N = 73). Elevated baseline self-critical perfectionism, but not dependency, predicted a greater likelihood of membership in the class of participants who demonstrated minimal symptom improvement over time. The second analysis examined whether baseline self-critical perfectionism also predicts depression symptom variability and instability. The LAS perfectionism model demonstrated that perfectionism accelerates depression symptom change during the first seven sessions of treatment, then has a decelerating effect on depression symptom change. CONCLUSIONS: Results indicated that higher baseline self-critical perfectionism predicted higher variability and instability in depression symptoms and variability in acceleration and deceleration, over the course of treatment.

Comparing Online and On-Site Cognitive Behavior Therapy in Major Depressive Disorder: Protocol for a Noninferiority Randomized Controlled Trial.

BACKGROUND: The incidence of mental health disorders in Canada is increasing with costs of CAD $51 billion (US $40 billion) per year. Depression is the most prevalent cause of disability while cognitive behavioral therapy (CBT) is the best validated behavioral depression treatment. CBT, when combined with mindfulness meditation (CBT-M), has strong evidence for increased efficacy. While randomized controlled trials (RCTs) have demonstrated online CBT-M efficacy, comparisons with in-office delivery are lacking. OBJECTIVE: The aim of this research is to assess whether online group CBT-M (with standard psychiatric care) is non-inferior in efficacy and more cost-effective than office-based, on-site group CBT-M at post-intervention and 6-months follow-up in major depressive disorder. The study will also assess whether digitally recorded data (ie, online workbooks completed, Fitbit step count, and online text messages) predict depression symptom reduction in online participants. METHODS: This single-center, two-arm, noninferiority RCT employs assessor-blinded and self-report outcomes and economic evaluation. The research site is the Centre for Addiction and Mental Health (Toronto), a research-based psychiatry institution where participants will be identified from service wait lists and through contacts with other Toronto clinics. Inclusion criteria are as follows: (1) aged 18-60 years, any ethnicity; (2) Beck Depression Inventory-II (BDI-II) of mild severity (score ≥14) with no upper severity limit; (3) Mini-International Neuropsychiatric Interview-confirmed, psychiatric major depressive disorder diagnosis; (4) fluent in English. All patients are diagnosed by staff psychiatrists. Exclusion criteria are as follows: (1) receipt of weekly structured psychotherapy; (2) observation of Diagnostic and Statistical Manual of Mental Disorders (5th Edition) criteria for severe alcohol or substance use disorder (in past 3 months), borderline personality disorder, schizophrenia (or other primary psychotic disorder), bipolar disorder, or obsessive-compulsive disorder; (3) clinically significant suicidal ideation (imminent intent or attempted suicide in the past 6 months); and (4) treatment-resistant depression. All participants receive standard psychiatric care, experimental participants receive online group CBT-M, and controls receive standard care in-office group CBT-M. The online group program (in collaboration with NexJ Health, Inc) combines smartphone and computer-accessed workbooks with mental health phone counselling (16 hours in 16 weeks) that coordinates software interactions (eg, secure text messaging and Fitbit-tracked walking). The primary outcome is BDI-II, and secondary outcomes are anxiety (Beck Anxiety Inventory), depression (ie, Quick Inventory of Depressive Symptomatology and 17-item Hamilton Depression Rating Scale), mindfulness (Five-Facet Mindfulness Questionnaire), quality of life (European Quality of Life Five Dimension), and pain (Brief Pain Inventory). RESULTS: Based on prior studies with the BDI-II and 80% power to reject an inferiority hypothesis with a 1-sided type I error rate of 5%, a sample of 78 per group is adequate to detect small-to-medium-effect sizes. CONCLUSIONS: This study assesses online CBT-M efficacy and noninferiority in relation to in-person CBT, and the cost-effectiveness of both interventions. TRIAL REGISTRATION: ClinicalTrials.gov NCT04825535; https://www.clinicaltrials.gov/ct2/show/NCT04825535. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/29726.

Technology supported mindfulness for obsessive compulsive disorder: Self-reported mindfulness and EEG correlates of mind wandering.

Cognitive Behavior Therapy (CBT) incorporating Exposure with Response Prevention (ERP) is the most efficacious treatment intervention for Obsessive Compulsive Disorder (OCD); however, there is a growing literature indicating that mindfulness based approaches can be beneficial in terms of managing OCD symptoms. The current study examined the potential benefits of using a consumer grade EEG-based biofeedback device (called "Muse") that permits individuals to engage in mindfulness meditation practices while at home. In this randomized controlled study, participants with a principal DSM-5 diagnosis of OCD (N = 71) were randomly assigned to eight weeks of: 1) a meditation program involving daily use of the "Muse" device, or 2) waitlist control. At weeks 1, 4, and 8, participants completed a five minute "open monitoring" practice while EEG data was recorded, and they completed self-report measures of mindfulness (FFMQ: Five Factor Mindfulness Questionnaire) and OCD symptoms (YBOCS: Yale-Brown Obsessive Compulsive Scale). Latent Difference Score (LDS) models demonstrated that the FFMQ "Non-Reactivity" facet and EEG-derived correlates of "Mind Wandering" (i.e., alpha, beta, but not delta or theta band power) were temporally associated with subsequent changes in YBOCS symptom scores. Participants in the Muse group (in comparison to the control group) experienced increased FFMQ "Non-Reactivity" and decreased mind wandering (increased alpha and beta band power), and in each case, these variables were associated with subsequent OCD symptom improvement. These results suggest that technology supported mindfulness training for OCD is associated with improvements in OCD symptoms, mindfulness and decreased mind wandering.

A multidimensional investigation of anxiety sensitivity and depression outcomes in cognitive-behavioral group therapy.

We examined how anxiety sensitivity - the fear of symptoms of anxiety due to their perceived harmful effects - and gender are associated with treatment trajectory and outcomes in a large outpatient sample (N = 278) who received 14-weeks of cognitive-behavioral group therapy (CBGT) for depression. Three dimensions of anxiety sensitivity (cognitive, physical, and social concerns) and depression were assessed at pre-treatment, and the latter was assessed weekly during treatment. Latent growth curve models supported a link between cognitive concerns (fears of losing control over thoughts) and greater improvement in depression near the end of treatment (i.e., weeks 10-14); gender did not moderate trajectory. Gender (i.e., identifying as a woman) and greater physical concerns (fears of physical consequences of arousal symptoms) were associated with completion of < 8 sessions. Results suggest that those with more cognitive concerns might require greater time in treatment and/or benefit most from the focus on maladaptive assumptions and core beliefs in later CBGT sessions. Future research, including investigation of intervening variables, may elucidate the mechanisms through which greater physical concerns and gender are associated with treatment non-completion. Results supported differential associations of anxiety sensitivity dimensions with depression treatment outcomes, though further research attention is needed.

Excessive reassurance seeking in depression versus obsessive-compulsive disorder: Cross-sectional and cognitive behavioural therapy treatment comparisons.

Excessive reassurance seeking (ERS) has been hypothesized as an important maintenance factor in depression and obsessive compulsive disorder (OCD). The present study examined the types of ERS in depression and OCD, the effects of CBT on ERS, predictors of ERS reduction, and the relation between ERS reduction and symptom change. METHOD: Treatment-seeking participants diagnosed with a depressive disorder (N = 361) or OCD (N = 156) completed the Reassurance Seeking Scale (RSS) and symptom measures before and following CBT treatment. Measures of intolerance of uncertainty and distress tolerance were completed pre-treatment as potential predictors of ERS change. RESULTS: Individuals with depression demonstrated higher pre-treatment ERS related to social attachment compared to those with OCD. ERS significantly decreased over treatment in both groups and change in ERS predicted symptom change among both OCD and depression groups. Higher pre-treatment intolerance of uncertainty significantly predicted less ERS change regardless of diagnosis. Distress tolerance was not associated with ERS changes. CONCLUSION: ERS is significantly related to symptom severity cross-sectionally as well as over treatment in depression and OCD, though types of ERS may differ. Higher intolerance of uncertainty may impede the reduction of ERS in CBT.

Morningness-eveningness scores predict outcomes differentially for depressed patients attending morning vs. afternoon day treatment streams.

At the Center for Addiction and Mental Health (CAMH) Integrated Day Treatment (IDT) program, each patient attends either a morning stream or an afternoon stream, but not both. We examined whether subjective chronotype, or the time of day an individual prefers to be most active and alert, predicted treatment outcomes differentially in depressed patients attending the morning vs. afternoon IDT streams. The Horne-Östberg Morningness-Eveningness Questionnaire (MEQ) was administered before IDT treatment to 203 consecutive patients experiencing a major depressive episode. Multiple regression was used to predict change in depression and quality of life scores based on treatment stream (morning or afternoon), baseline MEQ scores and the treatment stream by MEQ interaction. The treatment stream by MEQ interaction was a highly significant predictor of both depression and quality of life change scores. Post-hoc analyses based on established MEQ categories revealed that definite evening chronotypes had significantly better responses in the morning stream than did morning chronotypes, and significantly worse responses in the afternoon stream relative to moderate evening or neutral chronotypes. There were insufficient morning chronotypes in the afternoon stream to assess clinical responses for this subgroup. In the morning stream only, there was a significant positive correlation between the change in MEQ scores after four weeks of IDT treatment (i.e. a shift to greater morningness) and the decrease in depression scores (r = .36, p = .003), consistent with a therapeutic phase advance in circadian rhythms. In sum, these preliminary data suggest that definite evening chronotypes may have the greatest relative benefit from attending the morning vs. afternoon IDT stream. As patients currently select which IDT stream they will attend, future work based on randomized treatment assignment and using passive actigraphy to assess circadian phase is currently planned to extend these preliminary findings.

Reassurance seeking in the anxiety disorders and OCD: Construct validation, clinical correlates and CBT treatment response.

BACKGROUND: Reassurance seeking has been hypothesized to be a key factor in the maintenance of anxiety and obsessive-compulsive disorders according to contemporary cognitive-behavioural therapy (CBT) approaches. The present study sought to examine the structure, clinical correlates, and malleability of reassurance seeking in the context of CBT treatment. METHODS: Treatment-seeking participants (N = 738) with DSM-IV-TR (American Psychiatric Association, 2000) panic disorder with agoraphobia (PD/A), social anxiety disorder (SAD), generalized anxiety disorder (GAD), and obsessive compulsive disorder (OCD) completed the Reassurance Seeking Scale (RSS) with other symptom measures prior to and following CBT treatment. RESULTS: A confirmatory factor analysis supported a three factor solution: the need to seek excessive reassurance regarding decisions, attachment and the security of relationships, and perceived general threat and anxiety. The RSS was moderately correlated with general measures of anxiety and depression as well as disorder-specific symptom scales. Further, CBT was found to produce changes in reassurance seeking across CBT treatments and these reductions were significantly associated with disorder-specific clinical improvement. CONCLUSION: Reassurance seeking appears to be a common factor across anxiety disorders and its reduction in CBT treatment is associated with improved clinical outcomes.

Does intolerance of uncertainty mediate improvement in anger during group CBT for GAD? A preliminary investigation.

BACKGROUND: Individuals with generalized anxiety disorder (GAD) have elevated intolerance of uncertainty (IU) and anger, and IU mediates the relationship between GAD symptoms and anger. AIMS: The current pilot study examined whether group cognitive behavioural therapy (CBT) improves anger in people with GAD, and the degree to which change in IU mediates improved anger. METHOD: Individuals diagnosed with GAD completed measures of worry, IU, and facets of anger, before and at the end of group CBT for GAD. RESULTS: Worry, IU, and internally felt and outwardly expressed anger, reduced significantly over treatment, but anger control (inwardly and outwardly) did not. CBT for GAD led to improvement in both internally felt and outwardly expressed anger, even though anger is not directly targeted in this treatment. Improvement in IU significantly mediated improvement in internally felt and outwardly expressed anger. CONCLUSIONS: This preliminary study contributes to the literature on the importance of IU in understanding worry and other symptoms such as elevated anger, experienced by people with excessive worry.

What Drives OCD Symptom Change During CBT Treatment? Temporal Relationships Among Obsessions and Compulsions.

Cognitive behavior therapy (CBT) is an effective treatment for obsessive-compulsive disorder (OCD). However, less is known about how obsessions and compulsions change during treatment, either in tandem, sequentially, or independently. The current study used latent difference score analysis to show path-analytic dynamic modeling of OCD symptom change during CBT. Four competing models of the temporal relationship between obsessions and compulsions were examined: no coupling (obsessions and compulsions are not dynamically related), goal directed (obsessions lead to subsequent changes in compulsions), habit driven (compulsions lead to subsequent changes in obsessions), and reciprocal. Treatment seeking participants (N = 84) with a principal diagnosis of OCD completed 12 weeks of CBT group therapy and completed measures assessing obsession and compulsion severity at pretreatment, Sessions 4 and 8, and end of treatment. Bivariate results supported the goal directed traditional CBT model, where obsession scores are temporally associated with subsequent changes in compulsion scores. These results have implications for theoretical and treatment modelling of obsessions and compulsions in OCD treatment.