A randomized controlled trial of self-directed versus therapist-directed cognitive-behavioral therapy for obsessive-compulsive disorder patients with prior medication trials.

Cognitive-behavioral therapy incorporating exposure and response prevention (ERP) is widely considered a first-line psychosocial treatment for patients with obsessive-compulsive disorder (OCD). However, a number of obstacles prevent many patients from receiving this treatment, and self-administered ERP may be a useful alternative or adjunct. Forty-one adult outpatients with a primary diagnosis of OCD, who reported at least 1 current or previous adequate medication trial, were randomly assigned to self-administered or therapist-administered ERP. Patients in both treatment conditions showed statistically and clinically significant symptom reduction. However, patients receiving therapist-administered ERP showed a superior response in terms of OCD symptoms and self-reported functional impairment. We discuss several potential reasons for the superiority of therapist-administered treatment, and propose a stepped-care integration of self-administered and therapist-administered interventions for OCD.

Group treatment for trichotillomania: behavior therapy versus supportive therapy.

In this randomized controlled trial, group behavior therapy (BT; n=12) was compared to group supportive therapy (ST; n=12) in the treatment of trichotillomania (TTM). Both treatments were also compared to a naturally occurring waiting period, the time period that participants waited for groups to form. Participants completing group BT experienced significantly greater decreases in self-reported hair-pulling symptoms and clinician-rated hair loss severity than did those in group ST. Decreases were significantly greater after treatment than after the naturalistic waiting period. In addition, a significantly higher percentage of those in the BT than ST condition were rated as much improved or very much improved on the Clinical Global Impression scale at posttreatment. However, despite substantial symptom improvement, TTM severity remained problematic at posttreatment. Specifically, few participants in either treatment met criteria for clinically significant change at posttreatment. In addition, relapse of symptoms occurred over the 6-month follow-up period. Results provided partial support for the short-term efficacy of group BT. However, the group format may not maximize the efficacy of BT for TTM. Thus, it is recommended that future BT research test either individual therapy or a combination of group and individual formats for TTM.

Are "obsessive" beliefs specific to OCD?: a comparison across anxiety disorders.

Cognitive models of obsessive-compulsive disorder (OCD) assign a central role to maladaptive beliefs about threat, uncertainty, importance and control of thoughts, responsibility, and perfection. Previous research has demonstrated that such beliefs relate to specific OCD symptoms in a theoretically meaningful way. The aim of the present study was to determine whether these beliefs are endorsed more strongly by OCD patients than by those with other anxiety disorders. Eighty-nine adult OCD patients, 72 anxious control (AC) patients, and 33 nonclinical control (NCC) participants completed a measure of obsessive beliefs as well as measures of depression and trait anxiety. Compared to NCCs and ACs, OCD patients more strongly endorsed beliefs related to threat estimation, tolerance of uncertainty, importance and control of thoughts, and perfectionism, but not inflated responsibility. Using revised, condensed subscales, OCD patients differed from ACs on beliefs about perfectionism and certainty and about importance and control of thoughts, but not on beliefs about threat estimation and inflated responsibility. When controlling for depression and trait anxiety, the OCD and AC group did not differ on most belief domains, except for a belief that it is possible and necessary to control one's thoughts. Results are discussed in light of evolving cognitive-behavioral theories that highlight appraisals of thought control and the use and effectiveness of varying thought control strategies.

A brief motivational intervention for treatment-refusing OCD patients.

Cognitive behavioral therapy involving exposure and response prevention (ERP) is the psychosocial treatment of choice for obsessive-compulsive disorder (OCD). Despite this, ERP is not widely used by mental health practitioners, and so dissemination of ERP and other empirically supported treatment (ESTs) has become a priority. Even so, utilization of ESTs such as ERP remains below 50% even among therapists who self-identify as having a cognitive behavioral orientation. Barriers to the acceptance of ERP include practical obstacles such as lack of training and the cost of treatment, but also patient variables such as treatment refusal. It has been estimated that approximately 25% of OCD patients refuse ERP. This paper describes a brief, 4-session readiness intervention (RI) designed to decrease ERP refusal among patients with OCD. In this study, 12 patients with OCD who had refused ERP were randomized to RI or wait-list (WL). 86% of participants in the RI condition and 20% of participants in WL condition agreed to begin ERP following the 4-week period. ERP following RI, but not WL, was associated with a decrease in OCD symptoms comparable to that observed in OCD patients who did not refuse ERP. However, ERP following RI was associated with a high drop-out rate (50%), a figure that exceeds that typically seen in OCD treatment studies. Techniques to reduce drop-out as well as directions for future research are discussed.

Anxiety sensitivity: stability in prospective research.

Several recent panic prevention studies suggest that anxiety sensitivity, as measured by the Anxiety Sensitivity Index (ASI), may not be stable under certain conditions. In two investigations [Behav. Ther. 32 (2001) 725; Disertation Abstr. Int. 62 (2001) 4226], wait-list or no-treatment conditions produced ASI scores at follow-up that were significantly reduced from baseline and comparable to those of the intervention groups. Although design characteristics could not rule out regression to the mean as the source of these changes, the authors suggested that these findings were most likely due to nonspecific factors such as reassurance, support, or the expectation of receiving subsequent treatment. The present study sought to replicate and extend these findings by analyzing the contribution of a detailed diagnostic assessment on ASI scores. Two cohorts of high-risk-for-panic participants scoring in the high range of the ASI were studied. Cohort 1 received a detailed diagnostic assessment and then either no-treatment or one of two anxiety sensitivity reduction interventions. Cohort 2 did not receive a detailed diagnostic assessment or an intervention. Both groups were followed up 2 weeks after baseline assessment. Results were consistent with the hypothesis that ASI total and subscale scores are unstable in the presence of structured interviews. Participants receiving a diagnostic assessment produced ASI scores that were significantly lower than at baseline with the average ASI score dropping from the high to the average range. ASI scores of participants not receiving a diagnostic assessment, however, were unchanged from baseline.

Dysfunctional action monitoring hyperactivates frontal-striatal circuits in obsessive-compulsive disorder: an event-related fMRI study.

Converging evidence suggests that hyperactivity in frontal-striatal circuits and in action-monitoring processes characterizes obsessive-compulsive disorder (OCD). It remains unclear, however, just how these abnormalities in brain function translate into the cognitive, affective, and behavioral manifestations of OCD. One possibility is that exaggerated or false error signals generated by the anterior cingulate (ACC) underlie compulsive behaviors by triggering the feeling that things are "not just right" even when no actual error has been made. Since recurrent compulsive behavior typically follows correct completion of a behavioral task (e.g., hand washing), ACC hyperactivity should be observed during correctly completed, high-conflict trials as well as during error trials. Frontal-striatal regions would also be expected to be activated during both trial types, as these regions are robustly associated with OCD across multiple neuroimaging paradigms. To test this hypothesis, 14 OCD patients and 14 matched controls completed a speeded reaction time task during functional magnetic resonance imaging (fMRI). Only correctly rejected, high-conflict trials produced excessive activation in both action monitoring (rostral and caudal ACC, LPFC) and frontal striatal regions (lateral orbitofrontal cortex (OFC), caudate, and thalamus) among OCD patients when compared to healthy controls. Portions of the posterior cingulate were also hyperactive among OCD patients. These results suggest that correctly rejected, high-conflict trials that require response inhibition may provide a better model than error trials of compulsive behaviors in OCD.

Cognitive-behavioral therapy for medication nonresponders with obsessive-compulsive disorder: a wait-list-controlled open trial.

BACKGROUND: Cognitive-behavioral therapy (CBT) is generally recommended for obsessive-compulsive disorder (OCD) patients who have failed to respond to approved medications. However, few studies of the efficacy of CBT have selected patients who did not respond to medications. METHOD: We selected 20 adult OCD (DSM-IV criteria) patients with a history of inadequate response to adequate doses of multiple medications, as well as a high rate of comorbid disorders. After a 1-month wait-list period, patients received 15 sessions of outpatient CBT incorporating exposure and ritual prevention. RESULTS: OCD severity (as measured with the Yale-Brown Obsessive Compulsive Scale) decreased significantly (p <.05) after treatment, and gains appeared to have been maintained over a 6-month follow-up period. Analysis of clinical significance indicated that 53% (8/15) of treatment completers met this criterion at posttreatment and 40% (6/15) met the criterion at 6-month follow-up. The sample was characterized as having generally poor insight and putting low effort into CBT; these factors significantly (p <.05) predicted degree of improvement. CONCLUSION: CBT is a useful treatment for OCD patients who have failed to respond adequately to multiple serotonin reuptake inhibitor medications. However, these results were attenuated compared with previous trials. Patients with a long history of poor response to medication may have poor insight and/or not put sufficient effort into treatment; these factors are likely to diminish treatment outcome.

Sympathetic magic in contamination-related OCD.

We examined whether patients with contamination-related obsessive-compulsive disorder (OCD) are characterized by sympathetic magic beliefs (i.e., an irrational understanding of how contagion is transmitted). We asked OCD patients (OCs), non-anxious control participants (NACs), and anxious control participants (ACs) to identify a "contaminated" object and rate its degree of contamination on a 0-100 scale. Next, we touched a clean pencil to the object, and participants rated the degree to which the pencil was contaminated. A second pencil was touched to the first pencil and was then rated. This process was continued for 12 pencils (12 degrees of removal from the original object). The same process was repeated using threat-non-relevant stimuli. Results indicated that for threat-relevant stimuli, OCs seemed to perceive a "chain of contagion" in which successive degrees of removal from the original object were not rated as less contaminated. In contrast, NACs and ACs quickly identified the pencils as not contaminated, suggesting that they recognize the contamination as degrading across objects. This difference was not seen using threat-nonrelevant stimuli. We also found that ratings of looming vulnerability (a belief that the contamination is spreading, approaching, or escalating in threat value) mediated the relationship between diagnostic group and the chain of contagion. We suggest that this process may be consistent with the sympathetic magic and disease-avoidance models of disgust, and that disgust may be a fruitful area for exploration in the study of OCD.

Virtual reality exposure therapy for the treatment of fear of flying: a controlled investigation.

Forty-five participants who refused to fly during a screening test and who also met Diagnostic and Statistical Manual of Mental Disorders criteria for specific phobia, agoraphobia, or panic disorder with agoraphobia were randomly assigned to 5 sessions of either virtual reality exposure (VRE) or attention-placebo group treatment (GT). At posttreatment, 65% of VRE participants and 57% of GT participants flew during a test flight. Both groups showed significant improvement following treatment on standardized self-report measures of flight anxiety, with a better outcome for the VRE group on 4 of 5 of these measures. At 6-month follow-up, however, most group differences had disappeared; VRE resulted in a better outcome on only 1 of 5 standardized flight anxiety measures.