Validation of the Chinese Version of Obsessive-Compulsive Inventory-Revised.

BACKGROUND: The Obsessive-Compulsive Inventory-Revised (OCI-R) is a psychometrically sound and valid self-report measure for evaluating the severity of six dimensions of obsessive-compulsive symptoms: washing, obsessing, hoarding, ordering, checking, and neutralising. We aimed to validate the Chinese version of the OCI-R (C-OCI-R) in patients with obsessive-compulsive disorder (OCD) in Hong Kong. METHODS: The C-OCI-R was forward and backward translated and reviewed by an expert panel and a focus group. The internal consistency and test-retest reliability (2-week interval) were examined. Confirmatory factor analysis was used to examine the construct validity of the C-OCI-R. Concurrent validity was examined by the correlation between the C-OCI-R and the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), whereas divergent validity was examined by the correlation of the C-OCI-R with the Beck Depression Inventory-Second Edition and the Hamilton Depression Rating Scale. RESULTS: 130 OCD patients were recruited. The C-OCI-R showed excellent internal consistency (Cronbach's alpha = 0.92) and test-retest reliability (Spearman's rho correlation coefficient = 0.96). The original six-factor model was supported by confirmatory factor analysis. Concurrent validity and divergent validity were established. However, the neutralising subscale may need further development, and the divergent validity of the obsessing subscale was unsatisfactory. The structure of OCD symptoms was similar in Chinese and western patients. CONCLUSION: The C-OCI-R is a valid and reliable measure for assessing the severity of obsessive-compulsive symptoms in local Chinese patients with OCD.

Common and dissociable regional cerebral blood flow differences associate with dimensions of psychopathology across categorical diagnoses.

The high comorbidity among neuropsychiatric disorders suggests a possible common neurobiological phenotype. Resting-state regional cerebral blood flow (CBF) can be measured noninvasively with magnetic resonance imaging (MRI) and abnormalities in regional CBF are present in many neuropsychiatric disorders. Regional CBF may also provide a useful biological marker across different types of psychopathology. To investigate CBF changes common across psychiatric disorders, we capitalized upon a sample of 1042 youths (ages 11-23 years) who completed cross-sectional imaging as part of the Philadelphia Neurodevelopmental Cohort. CBF at rest was quantified on a voxelwise basis using arterial spin labeled perfusion MRI at 3T. A dimensional measure of psychopathology was constructed using a bifactor model of item-level data from a psychiatric screening interview, which delineated four factors (fear, anxious-misery, psychosis and behavioral symptoms) plus a general factor: overall psychopathology. Overall psychopathology was associated with elevated perfusion in several regions including the right dorsal anterior cingulate cortex (ACC) and left rostral ACC. Furthermore, several clusters were associated with specific dimensions of psychopathology. Psychosis symptoms were related to reduced perfusion in the left frontal operculum and insula, whereas fear symptoms were associated with less perfusion in the right occipital/fusiform gyrus and left subgenual ACC. Follow-up functional connectivity analyses using resting-state functional MRI collected in the same participants revealed that overall psychopathology was associated with decreased connectivity between the dorsal ACC and bilateral caudate. Together, the results of this study demonstrate common and dissociable CBF abnormalities across neuropsychiatric disorders in youth.

Moderators and predictors of response to cognitive-behavioral therapy augmentation of pharmacotherapy in obsessive-compulsive disorder.

BACKGROUND: Cognitive-behavioral therapy (CBT) consisting of exposure and response prevention (EX/RP) is efficacious as a treatment for obsessive-compulsive disorder (OCD). However, about half of patients have a partial or poor response to EX/RP treatment. This study examined potential predictors and moderators of CBT augmentation of pharmacotherapy, to identify variables associated with a poorer response to OCD treatment. METHOD: Data were drawn from a large randomized controlled trial that compared the augmenting effects of EX/RP to stress management training (SMT; an active CBT control) among 108 participants receiving a therapeutic dose of a serotonin reuptake inhibitor (SRI). Stepwise regression was used to determine the model specification. RESULTS: Pretreatment OCD severity and gender were significant moderators of outcome: severity affected SMT (but not EX/RP) outcome; and gender affected EX/RP (but not SMT) outcome. Adjusting for treatment type and pretreatment severity, significant predictors included greater co-morbidity, number of past SRI trials, and lower quality of life (QoL). Significant moderators, including their main-effects, and predictors accounted for 37.2% of the total variance in outcome, comparable to the impact of treatment type alone (R2=30.5%). These findings were replicated in the subgroup analysis of EX/RP alone (R2=55.2%). CONCLUSIONS: This is the first randomized controlled study to examine moderators and predictors of CBT augmentation of SRI pharmacotherapy. Although effect sizes for individual predictors tended to be small, their combined effect was comparable to that of treatment. Thus, future research should examine whether monitoring for a combination of these risk factors and targeting them with multi-modular strategies can improve EX/RP outcome.

The child PTSD Symptom Scale: a preliminary examination of its psychometric properties.

Reports on the development and preliminary validation of the Child PTSD Symptom Scale (CPSS) for children and adolescents. The CPSS is a new instrument that was developed to assess the severity of Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) posttraumatic stress disorder symptoms in children exposed to trauma. The CPSS was administered to 75 school-age children approximately 2 years after the 1994 Northridge, California, earthquake. The psychometric properties of the CPSS show high internal consistency and test-retest reliability for both the total score and the three subscales. Convergent validity with the Child Post-Traumatic Stress Disorder Reaction Index (CPTSD-RI) was established. As expected, the correlations of the CPSS with depression and anxiety measures were lower than those with the CPTSD-RI, providing some support for discriminant validity of the CPSS. These results suggest that the CPSS is a useful tool for the assessment of posttraumatic stress disorder (PTSD) severity and for the screening of PTSD diagnosis among traumatized children.

Patterns of recovery from trauma: the use of intraindividual analysis.

Patterns of recovery from sexual and nonsexual assault were examined. Two studies containing data from female victims of these assaults were analyzed. In Study 1, victims (N = 101) underwent 12 weekly assessments with measures of posttraumatic stress disorder (PTSD), depression, and state anxiety. In Study 2, victims (N = 108) underwent monthly assessments on the same measures. The authors examined the effects of type of trauma and time of peak reaction on long-term recovery using intraindividual analysis of change. In both studies, initial and peak reactions of rape victims were more severe than were those of nonsexual assault victims on all measures of psychopathology. Victims with delayed peak reaction exhibited more severe pathology at the final assessment than did victims with early peak reaction. Results of Study 2 indicated a slower recovery rate from sexual than nonsexual assault; in Study 1 a similar pattern of recovery emerged. The advantages of an individual-focused, longitudinal approach to recovery from a trauma are discussed.

Memory and memory confidence in obsessive-compulsive disorder.

Pathological doubt, often found in individuals with obsessive-compulsive disorder (OCD), has been theoretically linked to memory deficits, but empirical evidence for such deficits has been mixed. In contrast, many studies suggest that individuals with OCD have low confidence in their memories. The present study aimed to build upon previous research by measuring memory accuracy and confidence in OCD using ecologically valid, idiographically-selected stimuli. Individuals with OCD (OCs), anxious controls (ACs), and nonanxious controls (NACs) were exposed to a set of objects that the OCs had identified as safe, unsafe, or neutral. Participants were then asked to recall as many objects as possible and to rate their confidence in each memory. This process was repeated 6 times, using the same stimuli for each trial. Contrary to hypothesis, no group differences emerged in memory accuracy. However, OCs' memory confidence for unsafe objects showed a progressive decline over repeated trials. This pattern was not observed among NACs or ACs. Furthermore, OCs with primary checking reported lower confidence in long-term memory than did OCs without primary checking. These results suggest that when OCs are repeatedly exposed to threat-related stimuli (such as repeated checking), their level of confidence in remembering these stimuli paradoxically decreases.

Women and traumatic events.

Posttraumatic stress disorder (PTSD) gained the status of a psychiatric disorder in 1980, although the syndrome had already been recognized widely for many years. PTSD is distinguished by alternations between reexperiencing of the traumatic event that triggered the PTSD in the first place and avoidance and numbing. Increased arousal (e.g., exaggerated startle reaction) also forms part of the diagnosis. Although the majority of trauma victims recover spontaneously, more than 30% develop persistent PTSD symptoms, with women being twice as likely as men to suffer PTSD. To date, the most studied psychosocial treatments for PTSD are the cognitive-behavioral interventions. Exposure therapy (systematic exposure to the traumatic memory in a safe environment) has been demonstrated to be quite effective with adult women who were sexually or nonsexually assaulted in adulthood as well as with women who were sexually abused in childhood. Supportive counseling does not appear as effective as exposure therapy, but is better than no therapy.

Exposure therapy in the treatment of PTSD among cocaine-dependent individuals: description of procedures.

An estimated 30% to 50% of cocaine-dependent individuals meet criteria for lifetime PTSD. This comorbidity has detrimental effects on clinical presentation, and treatment course and outcome. Cocaine dependence is associated with increased rates of exposure to trauma, more severe symptoms, higher rates of treatment attrition and retraumatization, and greater vulnerability to PTSD when compared to other substance use disorders. These associations underscore the need for effective treatments that address issues particular to PTSD in a manner tolerable to cocaine-dependent individuals. This article describes a manualized psychotherapy developed specifically for individuals with PTSD and cocaine dependence. Concurrent Treatment of PTSD and Cocaine Dependence (CTPCD) provides coping skills training, cognitive restructuring techniques, and relapse prevention strategies to reduce cocaine use. In-vivo and imaginal exposure therapy techniques are incorporated to reduce PTSD symptom severity. Primary treatment goals include psychoeducation specific to the interrelationship between PTSD and cocaine dependence, and clinically meaningful reductions in cocaine use and PTSD symptomatology. Secondary goals include a reduction in HIV high-risk behaviors and improved functioning in associated areas, such as anger and negative affect management.

Exposure therapy in the treatment of PTSD among cocaine-dependent individuals: preliminary findings.

Individuals (n = 39) participated in an outpatient, 16-session individual, manual-guided psychotherapy designed to treat concurrent PTSD and cocaine dependence. Therapy consisted of a combination of imaginal and in-vivo exposure therapy techniques to treat PTSD symptoms and cognitive-behavioral techniques to treat cocaine dependence. Although the dropout rate was high, treatment completers (i.e., patients who attended at least 10 sessions; n = 15) demonstrated significant reductions in all PTSD symptom clusters and cocaine use from baseline to end of treatment. Significant reductions in depressive symptomatology, as measured by the Beck Depression Inventory, and psychiatric and cocaine use severity, as measured by the Addiction Severity Index, were also observed. These improvements in PTSD symptoms and cocaine use were maintained over a 6-month follow-up period among completers. The average pre- to posttreatment effect size was 1.80 for PTSD symptoms and 1.26 for drug and alcohol use severity. Baseline comparisons between treatment completers and noncompleters revealed significantly higher avoidance symptoms, as measured by the Impact of Events Scale, and fewer years of education among treatment noncompleters as compared to completers. This study provides preliminary evidence to suggest that exposure therapy can be used safely and may be effective in the treatment of PTSD in some individuals with cocaine dependence. However, the study is limited by the uncontrolled nature of the study design, small number of subjects, and high dropout rate.

Posttraumatic stress disorder in rape victims: autonomic habituation to auditory stimuli.

Impaired capacity for physiological habituation may contribute to the persistence of PTSD. Habituation of autonomic responses to auditory tones was examined in 43 women in three groups: 14 adult female rape survivors with chronic PTSD, 11 without PTSD, and a comparison group of 18 who had not been raped. There were no significant differences among the groups in baseline cardiac or electrodermal activity. The PTSD group showed significantly slower electrodermal habituation, as measured by trials to extinction and percentage of nonhabituators, than did the comparison groups. The present study found slower habituation of electrodermal responses for PTSD rape victims to neutral stimuli than for non-PTSD victims and nonvictims.

Inflated perception of responsibility for harm in obsessive-compulsive disorder.

The present study examined the proposition that inflated responsibility is implicated in obsessive compulsive disorder (OCD). Compared to non-anxious control participants (NACs), and an anxious control group with generalized social phobia (GSPs), we predicted that individuals with OCD (OCs) would exhibit a greater urge to rectify situations involving potential risk, would report more distress upon leaving such situations unrectified, and would feel more personal responsibility if the unrectified situations resulted in harm. Fifteen OCs, 15 NACs, and 15 GSPs completed the Obsessive Compulsive Responsibility Scale (OCRS), which included low-risk, OC-relevant, and high-risk situations. Compared to NACs and GSPs, OCs reported more urges, distress, and responsibility in low-risk and OC-relevant situations; no group differences were detected on high-risk situations. GSPs and NACs differed only in their responsibility in OC-relevant situations, with GSPs reporting higher responsibility than controls. Our results suggest that compared to OCs, NACs, and GSPs can better differentiate between situations that merit concern and ones that do not.

Stability of emotions for traumatic memories in acute and chronic PTSD.

While memory for central factual information regarding an emotional event is considered to be relatively accurate, memory for emotions seem to be quite inaccurate (Christianson & Safer, 1995). We extended this line of research to examine memory for the emotional intensity surrounding a traumatic event (e.g., memory for the fear and horror of the event). We conducted a series of two studies. In Study 1, we examined memory for the emotional intensity of the traumatic event in recent sexual or non-sexual assault victims with acute PTSD at 2 and 12 weeks following the assault. In Study 2, we compared memory for emotional intensity in sexual and non-sexual assault victims with either acute or chronic PTSD at initial assessment and 12 weeks later. For both studies, participants were asked to recall general emotional intensity, fear intensity, and dissociative intensity of the traumatic event. Results suggested that memory for the fear of the traumatic event did not fluctuate over time. However, memory for the general emotional and dissociative intensity did fluctuate over time, decreasing for individuals with acute PTSD and increasing for individuals with chronic PTSD.

Evaluation of the German version of the PTSD Symptom Scale (PSS).

The psychometric properties of the PTSD Symptom Scale (PSS) were evaluated in a clinical sample of severely injured in-patients after a traffic accident (n = 123). The PSS contains 17 items which were derived from the DSM-III-R criteria of posttraumatic stress disorder (PTSD). The results indicate that the PSS has satisfactory reliability and validity (internal and external). The results are in correspondence with the results of Foa et al. using a sample of rape and non-sexual-assault patients.

The investigation of exposure and cognitive therapy: comment on Tarrier et al (1999).

This article outlines concerns relating to the N. Tarrier et al. (1999) investigation comparing imaginal exposure and cognitive therapy. Specifically, the authors offer N. Tarrier et al. the opportunity to operationally define and clarify the claim that more patients treated by imaginal exposure "worsened" during treatment. Equally, in light of N. Tarrier et al.'s low effect sizes in relation to past research the authors also highlight the need to utilize accountable treatment integrity checks.

The effect of practice on recall of emotional information in individuals with generalized social phobia.

Understanding memory processes in social anxiety is important because these individuals often report negative memories of anxiety-provoking situations and because of the recent emphasis on learning and memory in models of anxiety. The authors examined the effect of learning on memory for negative social, positive social, and nonsocial information using the retrieval-induced forgetting paradigm in individuals with generalized social phobia (GSPs) and in nonanxious controls (NACs). Words were presented in 1 of 3 practice conditions: practiced words from a practiced category, unpracticed words from a practiced category, and unpracticed words from an unpracticed category. GSPs and NACs showed the same patterns of memory for practice categories for positive social and nonsocial words. However, for negative social words, GSPs benefited less from practice and were hurt less from the effect of practicing competing negative social information than were NACs. This pattern of processing may hamper GSPs' learning of, and habituation to, negative social information.

Fixity of belief, perceptual aberration, and magical ideation in obsessive-compulsive disorder.

Clinicians and researchers have pondered the intersection of obsessive-compulsive disorder (OCD) and psychosis. We examined the records of 395 individuals seeking treatment for OCD and classified participants according to their most frequent or distressing obsession and compulsion. All participants completed measures of fixity of belief, perceptual distortions, magical ideation, and psychotic symptoms. Results indicated that individuals who reported fear of harming self or others via overwhelming impulse or by mistake, and those with religious obsessions, had poorer insight and more perceptual distortions and magical ideation than did individuals with other types of obsessions. These results did not appear to reflect mere differences in OCD severity. Results are discussed in light of previous findings showing that psychotic-like symptoms are associated with attenuated treatment outcome in OCD. More research is needed to assess the absolute magnitude of psychotic-like features in OCD patients with impulse/mistake and religious obsessions and to examine whether these features interfere with standard cognitive-behavioral therapy.

Memory bias in generalized social phobia: remembering negative emotional expressions.

In two experiments, the authors examined memory for facial emotional expressions in patients with generalized social phobia (GSP) and in nonanxious control (NAC) participants. Three main questions were addressed. First, do patients with GSP differ from NAC participants in their overall memory for facial expressions? Second, do patients with GSP exhibit a memory bias for negative versus nonnegative expressions? Third, if such a bias exists, is it specific to angry expressions? The results of both experiments indicated that patients with GSP have better memory for all facial expressions than do NAC participants. Results of experiment 2 suggest that patients with GSP exhibit enhanced recognition for negative compared with nonnegative expressions; in contrast, NAC participants did not exhibit such enhancement. Results concerning specificity were equivocal. The importance of examining cognitive biases in patients with GSP via the use of facial expression is discussed.

Effectiveness of exposure and ritual prevention for obsessive-compulsive disorder: randomized compared with nonrandomized samples.

The efficacy of exposure and ritual prevention (EX/RP) for reducing symptoms of obsessive-compulsive disorder (OCD) has been demonstrated in several randomized controlled trials (RCTs). However, procedures used in these studies to maximize experimental control may have limited their generalizability to typical clinical practice. Treatment outcome data from 110 clinical patients receiving EX/RP on an outpatient fee-for-service basis were compared with findings from 4 RCTs of EX/RP. Adult patients in the clinical sample were not excluded because of treatment history, concomitant pharmacotherapy, psychiatric comorbidity, age, or OCD severity. Clinical patients achieved substantial and clinically meaningful reductions in their OCD and depressive symptoms following EX/RP, which were comparable with those reported in the RCTs. Findings indicate that EX/RP is a potent treatment for OCD, and its benefits are not limited to select patient samples.

Exploring the roles of emotional numbing, depression, and dissociation in PTSD.

Some researchers consider emotional numbing a cardinal feature of posttraumatic stress disorder (PTSD). Others view numbing symptoms as representing an overlap between PTSD, depression, and dissociation. In this study, we examined the ability of early emotional numbing, depression, and dissociation symptoms to predict PTSD. One-hundred sixty-one women who were recent victims of sexual or nonsexual assault were assessed prospectively for 12 weeks. Emotional numbing, depression, and dissociation were each associated with initial PTSD severity. Notably, regression analyses revealed that after depression and dissociation were accounted for, early numbing contributed to the prediction of later PTSD.