A pilot randomized controlled trial of time-intensive cognitive-behaviour therapy for postpartum obsessive-compulsive disorder: effects on maternal symptoms, mother-infant interactions and attachment.

BACKGROUND: There is increasing recognition that perinatal anxiety disorders are both common and potentially serious for mother and child. Obsessive-compulsive disorder (OCD) can be triggered or exacerbated in the postpartum period, with mothers reporting significant effects on parenting tasks. However, there is little evidence concerning their effective treatment or the impact of successful treatment on parenting. METHOD: A total of 34 mothers with OCD and a baby of 6 months old were randomized into either time-intensive cognitive-behaviour therapy (iCBT) or treatment as usual (TAU). iCBT took place after randomization at 6 months postpartum and was completed by 9 months. Maternal symptomatology, sensitivity in mother-infant interactions and parenting were assessed at baseline and reassessed at 12 months postpartum. At 12 months attachment was also assessed using Ainsworth's Strange Situation Procedure. A healthy control group of mothers and infants (n = 37) underwent the same assessments as a benchmark. RESULTS: iCBT was successful in ameliorating maternal symptoms of OCD (controlled effect size = 1.31-1.90). However, mother-infant interactions were unchanged by treatment and remained less sensitive in both OCD groups than a healthy control group. The distribution of attachment categories was similar across both clinical groups and healthy controls with approximately 72% classified as secure in each group. CONCLUSIONS: iCBT is an effective intervention for postpartum OCD. Sensitive parenting interactions are affected by the presence of postpartum OCD and this is not improved by successful treatment of OCD symptoms. However, the overall attachment bond appears to be unaffected. Longitudinal studies are needed to explore the impact of postpartum OCD as the child develops.

Investigating perceptions of disgust in older adult residential home residents.

OBJECTIVES: As people become increasingly physically dependent as they make the transition into older age, they may lose the ability to control bodily functions. Problems with eating, voiding and washing can be linked with feelings of disgust and, given the necessity for some of being assisted with intimate care activities, it has been suggested that self-focused disgust and concerns over the disgust of others may become important preoccupations in older people, with the potential to further impair their quality of life. METHOD: In a mixed-methods study, feelings of disgust in 54 physically dependent older adults living in residential homes were investigated. Participants completed measures of disgust sensitivity, mood, and two new scales assessing feelings of self-disgust and perceived other-disgust related to intimate care activities. Six of the residents who reported high levels of self-disgust also participated in semi-structured interviews. RESULTS: Results indicated that disgust was uncommon. Where present, self-disgust was related to perceptions of others' feelings of disgust and general disgust sensitivity. These results were benchmarked against 21 community-dwelling older adults, who reported believing they would feel significantly more disgusting if they were to start receiving assistance. A thematic analysis identified the importance of underlying protective factors, the use of strategies and carer characteristics in ameliorating feelings of disgust. CONCLUSION: The results are discussed with reference to the disgust literature, with recommendations being made for ways in which self-disgust can be minimised in those making the transition to residential homes.

An experimental investigation of factors involved in the decision to undertake genetic testing for schizophrenia.

BACKGROUND: The psychological issues surrounding genetic testing, particularly decision-making processes, are not well understood. Previous studies suggest that apparently "nondirective" strategies intended to help individuals consider the consequences of undergoing predictive testing for physical illness can influence the decision. AIMS: To investigate the influence of selectively focussing on different aspects of previously provided information concerning genetic testing for schizophrenia. METHOD: Community participants (n = 120) rated how likely they would be to arrange to have a genetic test for schizophrenia if it were available, before and after being given detailed information about schizophrenia and the implications of testing. Participants were then randomly allocated to four groups, and were implicitly focused on the negative issues (negative group), the positive issues (positive group), both the negative and positive issues (all-focusing group) or schizophrenia-irrelevant health-related issues (control group). All issues on which the experimental groups focussed were included in the information provided and the form of questioning meets current definitions of nondirectiveness. RESULTS: Hypothetical decisions whether to arrange a genetic test for schizophrenia were influenced by the issues on which participants had focused; the positive group were more likely to say they would be tested relative to the other groups. CONCLUSIONS: Decisions about genetic testing for schizophrenia were influenced by the specific issues on which individuals were encouraged to focus at that time.

Mind the gap: Improving the dissemination of CBT.

Empirically supported psychological treatments have been developed for a range of psychiatric disorders but there is evidence that patients are not receiving them in routine clinical care. Furthermore, even when patients do receive these treatments there is evidence that they are often not well delivered. The aim of this paper is to identify the barriers to the dissemination of evidence-based psychological treatments and then propose ways of overcoming them, hence potentially bridging the gap between research findings and clinical practice.

Neutralizing increases discomfort associated with obsessional thoughts: an experimental study with obsessional patients.

Cognitive-behavioral theories suggest that the development of neutralizing is crucial in the development and persistence of obsessional problems (OCD). Twenty-nine patients with a Diagnostic and Statistical Manual of Mental Disorders (4th ed., American Psychiatric Association, 1994) diagnosis of OCD were randomly allocated to 2 conditions. Both listened to repeated recorded presentations of their intrusive thoughts and either neutralized (experimental group) or distracted themselves (control). Discomfort was rated during this 1st phase and then during a 2nd phase without neutralizing or distraction. The experimental group showed a similar level of discomfort in the 1st phase, which significantly reduced during the period compared with controls. The experimental group experienced significantly more discomfort during the 2nd phase, and significantly stronger urges to neutralize and distract at the end of this phase than controls.

The impact of screening for Type 2 diabetes in siblings of patients with established diabetes.

BACKGROUND: Targeted screening for Type 2 diabetes has been proposed as a method of identifying people with, or at risk of, the disease in order to implement preventive care. AIM: To assess the changes in anxiety, well-being, and cognitions associated with screening for Type 2 diabetes in people at increased risk of diabetes after 1 year; and to identify potential predictors of increased anxiety and lower well being over this period. DESIGN AND SETTING: One-year follow up of a cohort of non-diabetic siblings of those with Type 2 diabetes registered with general practitioners in Oxfordshire and Northamptonshire who were identified for participation in a programme to undertake sib-pair genetic analysis. METHODS: Potential families were selected through identification of people with Type 2 diabetes. Family members aged 35-74 years, who did not have diabetes and who were willing to participate in the study, completed measures before receiving the results of a fasting plasma glucose test, and 1 year later. Measures included the Spielberger State Anxiety Scale-short form (SSAI-SF), the Well-Being Questionnaire 12 item scale (WBQ-12), and measures of cognitions about developing diabetes. The Health Anxiety Inventory (HAI) was completed before receiving the results of the tests to assess its relationship with anxiety at 1 year. RESULTS: A cohort of 431 individuals was identified, of whom 328 (76%) returned fully completed WBQ scales both initially and at 1 year. State anxiety measured with the SSAI-SF fell from 34.5 (95% CI 33.4-35.6) to 32.3 (31.2-33.4) at 1 year (P < 0.0001). Mean WBQ-12 scores rose (i.e. improved) from 26.8 (26.0-27.4) to 27.4 (26.7-28.1) (P = 0.008). SSAI-SF and WBQ-12 mean scores over 1 year did not differ between participants receiving a normal or an at-risk test result. However, those receiving an at-risk test result were more likely, at 1 year, to consider themselves at increased likelihood of developing diabetes (P < 0.001) and to report thinking about what it would be like to develop diabetes (P = 0.006). A score in the upper tertile of the initial HAI was associated with an increased level of anxiety at 1 year (adjusted odds ratio 2.0, 95% CI 1.2-3.4, P = 0.006). CONCLUSIONS: There is no evidence that an 'at-risk' test result leads to sustained anxiety or reduced well being at 1 year compared with those receiving a normal test result. However, further studies are required to clarify levels of anxiety prior to screening to assess the overall impact of the process.

The Health Anxiety Inventory: development and validation of scales for the measurement of health anxiety and hypochondriasis.

BACKGROUND: A self-rated measure of health anxiety should be sensitive across the full range of intensity (from mild concern to frank hypochondriasis) and should differentiate people suffering from health anxiety from those who have actual physical illness but who are not excessively concerned about their health. It should also encompass the full range of clinical symptoms characteristic of clinical hypochondriasis. The development and validation of such a scale is described. METHOD: Three studies were conducted. First, the questionnaire was validated by comparing the responses of patients suffering from hypochondriasis with those suffering from hypochondriasis and panic disorder, panic disorder, social phobia and non-patient controls. Secondly, a state version of the questionnaire was administered to patients undergoing cognitive-behavioural treatment or wait-list in order to examine the measure's sensitivity to change. In the third study, a shortened version was developed and validated in similar types of sample, and in a range of samples of people seeking medical help for physical illness. RESULTS: The scale was found to be reliable and to have a high internal consistency. Hypochondriacal patients scored significantly higher than anxiety disorder patients, including both social phobic patients and panic disorder patients as well as normal controls. In the second study, a 'state' version of the scale was found to be sensitive to treatment effects, and to correlate very highly with a clinician rating based on an interview of present clinical state. A development and refinement of the scale (intended to reflect more fully the range of symptoms of and reactions to hypochondriasis) was found to be reliable and valid. A very short (14 item) version of the scale was found to have comparable properties to the full length scale. CONCLUSIONS: The HAI is a reliable and valid measure of health anxiety. It is likely to be useful as a brief screening instrument, as there is a short form which correlates highly with the longer version.

Causing harm and allowing harm: a study of beliefs in obsessional problems.

This study investigates two factors hypothesised as relevant to obsessional problems because of the way in which they influence decisions whether or not to act to prevent harm. These are (i) the way in which intrusive thoughts increase the internal awareness of harm, and confront the person with the possibility of taking action to prevent such harm and (ii) the extent to which there is some obvious external factor which increases awareness of the possibility of preventing harm. Obsessional patients, anxious and non-clinical controls completed a scale which systematically measured these factors across a wide range of situations. Results across all situations evaluated confirmed previous findings that both obsessionals and nonobsessionals were more likely to report acting to prevent harm when awareness of it is prompted by an intrusion than when it is not. It was also found that participants in all groups acted more 'obsessionally' when a scenario is described in ways which suggest that harm may be by 'commission' than when it is described in terms of an 'omission'. When scenarios about which each individual is most disturbed were analysed, anxious and non-clinical controls continued to differentially rate omission and commission situations; as predicted, this differential was not present for obsessional patients. It is concluded that obsessionals are more sensitive to omission than are nonobsessionals when considering scenarios about which they are concerned, and that this sensitivity is one factor influencing the decision whether to act to prevent harm.

Recall and recognition memory for spider information.

Two experiments were devised to examine the effect of anxiety on memory for threatening information in those with spider phobia. Those with spider phobia, control participants, and those with other phobias were shown video clips of spiders. In the recognition task, participants were asked to state whether they remembered having seen specific video clips of spiders that had been presented to them previously. In the recall task, they were asked to remember and note as much detail as possible about each of a second series of video clips of spiders. Those with spider phobia were no different from the other two groups in their ability to recognize spider stimuli or in the amount of detail they were able to recall.

Responsibility attitudes and interpretations are characteristic of obsessive compulsive disorder.

The cognitive-behavioural theory of Obsessive Compulsive Disorder (OCD) proposes that a key factor influencing obsessional behaviour is the way in which the intrusive cognitions are interpreted. The present paper reports an investigation of links between clinical symptoms (of anxiety, depression and obsessionality) and responsibility beliefs. These beliefs include not only measures of general responsibility attitudes (assumptions) but also more specific responsibility appraisals consequent on intrusive cognitions. The characteristics of two new questionnaires specifically designed to measure these beliefs were assessed in patients suffering from Obsessive Compulsive Disorder, in patients suffering from other anxiety disorders and in non-clinical controls. The scales measuring negative beliefs about responsibility were found to have good reliability and internal consistency. Comparisons between criterion groups indicate considerable specificity for both assumptions and appraisals with respect to OCD. There was also good evidence of specificity in the association between responsibility cognitions and obsessional symptoms across groups, and that this association was not a consequence of links with anxiety or depressive symptoms. Although the two measures were correlated, they each made unique contributions to the prediction of obsessional symptoms. Overall, the results are consistent with the hypothesis that responsibility beliefs are important in the experience of obsessional problems.

The effects of 'non-directive' questioning on an anticipated decision whether to undergo predictive testing for heart disease: an experimental study.

This study investigates how individuals can be helped to make decisions about predictive genetic testing. Participants (n = 120) rated how likely they would be to opt for predictive testing for heart disease if it were available, and other variables such as anxiety about heart disease. They received information on predictive testing for heart disease and ratings were repeated. Participants were then randomly allocated to one of three groups and focused on the personal relevance of positive issues or negative issues which had been mentioned as part of the standardised information previously given. The third group focused on issues irrelevant to testing for heart disease. The form of questioning used in this focusing manipulation was intended to model the processes involved in non-directive questioning. Results showed a significant increase in likelihood of testing in the positive group, and a significant decrease in the negative group. There was also a significant decrease in rated anxiety about heart disease and perceived severity of an increased susceptibility to heart disease of the negative group relative to the positive and control groups. The results may have implications for the ways in which pre-test counselling is carried out.

The effect of nondirective questioning on women's decisions whether to undergo bone density screening: an experimental study.

This study investigated the effects of nondirective counseling on health screening decisions. Ninety women (mean age = 51 years) received information about bone density screening and osteoporosis. They were then randomly allocated to 1 of 4 groups and were encouraged to focus on positive issues about bone density screening (positive group), on negative issues (negative group), on both positive and negative issues (all-focusing group), or on issues relating to the common cold (control group). Women were asked to rate how likely they would be to opt for bone density screening if they saw it available. After being informed that they could have bone density screening, actual uptake was assessed. It was found that the issues on which individuals focused significantly influenced their rate likelihood of opting for the scan. Rated likelihood of testing was significantly associated with whether individuals actually did opt for testing when it was subsequently offered to them.

Brief cognitive therapy for panic disorder: a randomized controlled trial.

Cognitive therapy (CT) is a specific and highly effective treatment for panic disorder (PD). Treatment normally involves 12-15 1-hr sessions. In an attempt to produce a more cost-effective version, a briefer treatment that made extensive use of between-sessions patient self-study modules was created. Forty-three PD patients were randomly allocated to full CT (FCT), brief CT (BCT), or a 3-month wait list. FCT and BCT were superior to wait list on all measures, and the gains obtained in treatment were maintained at 12-month follow-up. There were no significant differences between FCT and BCT. Both treatments had large (approximately 3.0) and essentially identical effect sizes. BCT required 6.5 hr of therapist time, including booster sessions. Patients' initial expectation of therapy success was negatively correlated with posttreatment panic-anxiety. Cognitive measures at the end of treatment predicted panic-anxiety at 12-month follow-up.

Obsessive-compulsive disorder, anxiety disorders, and self-esteem: an exploratory study.

In a preliminary investigation of the link between self-esteem and obsessional problems, patients with OCD were compared with people suffering from other anxiety disorders and non-anxious controls. A questionnaire was devised which allowed the reliable coding of open ended responses focussed on issues surrounding self-worth; standardized measures of self-esteem and clinical symptomatology were also administered. Results indicated that both clinical groups differed significantly from non-clinical controls on generalized self-esteem assessments. There was some evidence of OCD specific effects; obsessionals were more likely than anxious controls to link their self-worth to other people and their relationships. They also regarded the possibility of causing harm as likely to result in other people making extreme negative and critical judgements of them; the other groups expected the responses of others towards them to be more lenient. The implications for future research and for treatment of OCD are discussed.

Understanding and treating obsessive-compulsive disorder.

The development of behaviour therapy for OCD and its evolution into cognitive behaviour therapy is described, highlighting the importance of a crucial series of experiments conducted by Rachman and colleagues in the mid-1970s. More recently, developments in cognitive theory suggest that the key to understanding obsessional problems lies in the way in which intrusive thoughts, images, impulses and doubts are interpreted. The important negative interpretations usually concern the idea that the person's action (or choice not to act) can result in harm to oneself or others. This responsibility interpretation has several consequences (such as motivating neutralising behaviour and other counter-productive strategies, increasing selective attention, increased negative mood); these serve to maintain the negative beliefs and therefore the obsessive-compulsive problem. Both general and specific aspects of cognitive-behavioural treatment are described. A number of treatment strategies which are specific to obsessional problems are described in clinical detail.

An experimental investigation of the role of safety-seeking behaviours in the maintenance of panic disorder with agoraphobia.

This study evaluates the hypothesis that safety-seeking behaviours play an important role in maintaining anxiety because they prevent patients from benefiting from disconfirmatory experience. Patients suffering from panic disorder with agoraphobia carried out a behaviour test, closely followed by an experimental session, which included a brief (15 min) period of exposure during which participants either stopped or maintained within-situation safety-seeking behaviours. When the behaviour test was repeated within two days, patients who had stopped their safety-seeking behaviours during the experimental session showed a significantly greater decrease in catastrophic beliefs and anxiety than those who had maintained safety-seeking behaviour. This difference was also reflected in questionnaires measuring clinical anxiety. These results are consistent with the cognitive hypothesis.

An experimental study of influences on the perceived likelihood of seeking genetic testing: "nondirectiveness" may be misleading.

It has been suggested that decision making involves the implicit weighing up of those advantages and disadvantages of possible options considered relevant at the time the decision is made. If this is so, the information that people have most readily available at the time of the decision would influence the decision outcome. The study reported here experimentally evaluates the effect of manipulating the issues on which individuals focus as a way of investigating subtle directive influences. Participants (n = 104) were interviewed about their anticipated likelihood of opting for testing for hereditary hemochromatosis. All participants were given standard information about hemochromatosis, including a description of the disorder as causing progressive damage over many years and an explanation that treatment is most effective if begun before the age of 30 years. Individuals were randomly allocated to groups according to age group (30 years and under, or over 30 years) and gender. Those allocated to the positive group were then encouraged to focus on positive aspects of the previously given information by considering the extent to which statements applied to them, whereas the negative group focused on negative aspects. The control group focused on an unrelated disease. Analyses of variance indicated that the focusing manipulation affected the likelihood of opting for testing. This effect interacted with age of respondent: in participants over 30, the positive group ratings of likelihood of testing increased, whereas in the negative group they decreased; in participants 30 and under, both the positive and negative groups showed an increased desire to be tested. The control group did not alter significantly. The relevance of these findings to "nondirective" approaches to genetic counseling is considered.

Cognitive-behavioural approach to understanding obsessional thinking.

BACKGROUND: Obsessional ruminations (obsessions without any accompanying overt compulsive behaviour) were previously considered especially difficult to treat. METHOD: Cognitive-behavioural theory regarding obsessional problems is discussed. Strategies for therapy developed on the basis of this theory are reviewed. RESULTS: The cognitive-behavioural theory of obsessive-compulsive disorder proposes that obsessional problems occur as a consequence of the particular meaning or significance which patients attach to the occurrence and/or content of intrusive thoughts. When intrusions are interpreted (appraised) as indicating increased personal responsibility, this results in both distress and the occurrence of neutralising behaviour. Cognitive-behavioural treatment seeks to change responsibility beliefs and appraisals, and thereby reduce distress and eliminate neutralising responses which usually occur as covert neutralising (mental rituals). Evidence is emerging for the success of therapy developed on this theoretical basis. CONCLUSIONS: Recent developments in the psychological conceptualisation of obsessional ruminations have improved the prospects for successful therapy.