Investigating an Acceptance and Commitment Therapy-Based Exposure Therapy Intervention in Treatment-Refractory OCD and Related Disorders: Changes in Psychological Flexibility, Treatment Engagement, and Treatment Perceptions.

While exposure therapy is the most effective psychological treatment for obsessive-compulsive disorder (OCD), anxiety, and traumatic stress-related disorders, it is not universally effective, indicating a need for further treatment optimization. This study investigated a shift in approach to exposure therapy with 29 treatment-refractory adults in an OCD clinic not responding to standard treatment, comprising habituation-based exposure therapy. Participants completed standard exposure as a continuation of standard clinic treatment, followed by an acceptance and commitment therapy (ACT) consultation session to assess psychological inflexibility processes interfering with treatment progress, and then an ACT-based exposure targeting behavior change through increasing psychological flexibility. After each exposure, participants and independent raters reported levels of psychological flexibility, rituals, distress, treatment engagement, and treatment perceptions. We observed that the shift to ACT-based exposure was associated with greater psychological flexibility, treatment engagement, treatment acceptability, and treatment preference. These findings suggest that there may be situations where ACT-based exposure has particular utility.

Evaluating the long-term (Three Year) durability of brief interventions targeting risk factors for psychopathology.

Despite their brevity, prior work indicates that computer-based interventions can substantially impact risk factors for psychopathology including anxiety sensitivity (AS), thwarted belongingness (TB), and perceived burdensomeness (PB). However, very few studies have assessed the long-term (> 1 year) effects of these interventions. The primary aim of the current study was to evaluate post-hoc, the long-term (3 year) durability of brief interventions targeting risk factors for anxiety and mood psychopathology using data from a pre-registered randomized clinical trial. Moreover, we were interested in evaluating whether mitigation in these risk factors mediated long-term symptom change. A sample determined to be at-risk for anxiety and mood pathology based on elevations on several risk factors (N = 303) was randomly assigned to one of four experimental conditions focused on: (1) reducing TB and PB; (2) reducing AS, (3) reducing TB,PB, and AS; or (4) a repeated contact control condition. Participants were assessed at post-intervention, one, three, six, 12, and 36 month follow-ups. Participants in the active treatment conditions showed sustained reductions in AS and PB through long-term follow-up. Mediation analyses suggested that reductions in AS mediated long-term reductions in anxiety and depression symptoms. These findings suggest that brief and scalable risk reduction protocols have long-term durability and efficacy both in terms of reducing risk factors for psychopathology.

COVID-19 Impact Battery: Development and Validation.

In addition to impacting the physical health of millions of Americans, the novel-coronavirus (COVID-19) pandemic is a significant psychological stressor due to both the threat of the illness itself and the mitigation strategies used to contain the spread. To facilitate understanding of the impact of COVID-19, validated measures are needed. Using a stepwise procedure in line with best-practice measurement procedures, the current report summarizes the procedures employed to create the COVID-19 Impact Battery (CIB). Two independent samples recruited via Amazon Mechanical Turk (N = 175, N = 642) and a third community sample (N = 259) were used for reliability and validity testing. Validation procedures yielded a battery consisting of three scales assessing COVID-19 related behaviors, worry, and disability. The behaviors scale contains three subscales assessing stockpiling, cleaning, and avoidance. The worry subscale also contains three subscales assessing health, financial and catastrophic concerns. In addition, we created a short version of the battery (CIB-S) to allow for more flexibility in data collection. In summary, we have provided reliability and validity information for the CIB and CIB-S, demonstrating that these measures can facilitate evaluation of the broad impact of COVID-19 on mental health functioning.

Examination of a brief computerized Cognitive Anxiety Sensitivity intervention on obsessive-compulsive symptoms.

OBJECTIVES: Despite the existence of several first-line treatments for obsessive-compulsive disorder (OCD), many patients fail to experience symptom reduction and/or do not complete treatment. As a result, the field has increasingly moved towards identifying and treating malleable underlying risk factors that may in turn improve treatment efficacy. One salient underlying risk factor, anxiety sensitivity (AS) cognitive concerns, has been found to be uniquely associated with obsessive-compulsive (OC) symptom dimensions. However, no studies have yet examined whether reductions in AS cognitive concerns will lead to subsequent reductions in OC symptoms. METHODS: The current study attempted to fill this gap by recruiting individuals reporting elevations on both AS cognitive concerns and at least one OC symptom dimension. Participants were randomly assigned to receive either a one-session AS cognitive concerns intervention (n = 35) or a single health information control session (n = 37). AS cognitive concerns were assessed at post-intervention and one-month follow-up. RESULTS: The active intervention produced significantly greater reductions in AS cognitive concerns post-intervention than the control intervention. However, this effect was no longer significant at one-month follow-up. Further, while there was not an effect of treatment condition on OC symptoms at one-month follow-up, changes in AS cognitive concerns from baseline to post-intervention mediated changes in OC symptoms at one-month follow-up. CONCLUSIONS: Findings support previous research attesting to the malleable nature of AS. Extending this research, findings provide initial support for the efficacy of AS interventions among individuals with elevated OC symptoms. PRACTITIONER POINTS: Clinicians should consider assessing anxiety sensitivity (AS) among patients with obsessive-compulsive disorder. If elevated, clinicians should consider targeting AS as an adjunct to treatment as usual.

A longitudinal investigation of trauma-specific rumination and PTSD symptoms: The moderating role of interpersonal trauma experience.

BACKGROUND: Interpersonal trauma (IPT) is one of the most commonly reported types of traumatic experiences and has the greatest likelihood of resulting in a diagnosis of posttraumatic stress disorder (PTSD). Relative to other types of trauma, victims of IPT report greater trauma-specific rumination, whereby they focus on negative consequences of the trauma on their life. Theoretical and empirical work suggest trauma-specific rumination leads to elevated posttraumatic stress symptoms (PTSS); however, there has been a dearth of research examining how trauma type may impact this association. Therefore, the current longitudinal study examined how the experience of IPT moderates the relationship between trauma-specific rumination and later PTSS. METHOD: Participants (N = 204) enrolled in a clinical trial completed self-report measures of trauma experience, trauma-specific rumination, and PTSS at baseline and 1-month follow-up appointments. RESULTS: Results revealed that IPT moderated the relationship between baseline rumination and 1-month trauma symptoms, even after covarying for participant age and sex, treatment condition, negative affect, and number of previously experienced traumas. Further, this moderation effect was specific to the PTSD numbing cluster. LIMITATIONS: Major limitations include measurement of PTSS via PCL-C rather than the PCL-5, as well as a limited sample size, precluding moderation analyses of other trauma types. CONCLUSIONS: The current study provides novel findings demonstrating specificity of index trauma type in the longitudinal relationship between rumination and PTSS. Future work is needed to examine how IPT impacts the development of pathways between rumination and PTSS.

Anxiety sensitivity prospectively predicts pandemic-related distress.

BACKGROUND: Anxiety sensitivity (AS) is a well-studied transdiagnostic risk construct that is believed to amplify responses to many forms of stress. The COVID-19 pandemic is a broad stressor with significant physical and social threats. In the current study, we were interested in ascertaining the degree to which AS would relate to distress and disability in the context of COVID-19. We hypothesized that AS would be associated with increased distress and disability. Moreover, we hypothesized that AS would be uniquely predictive while controlling for other relevant risk factors such as age, race, and perceived local COVID-19 infection rates. METHOD: Participants (N = 249) were U.S. adults assessed using online data resourcing and re-assessed one month later. RESULTS: At the first time point, during the beginning phases of the COVID-19 pandemic, AS was significantly related to COVID-19 distress and disability with a moderate effect size. AS was longitudinally associated with higher COVID-19 worry and depression. LIMITATIONS: Our findings are limited by the use of a relatively small online sample. Additionally, assessment of pre-pandemic and post-pandemic symptoms and functioning would be beneficial for future research. CONCLUSIONS: Taken together, the current study provided evidence consistent with AS as a causal risk factor for the development of distress and depression during the COVID-19 pandemic.

Actual versus perceived infection rates of COVID-19: Impact on distress, behavior and disability.

OBJECTIVE: Accurate threat appraisal is central to survival. In the case of the coronavirus pandemic, accurate threat appraisal is difficult due to incomplete medical knowledge as well as complex social factors (e.g., mixed public health messages). The purpose of this study was to evaluate the degree to which individuals accurately perceive COVID-19 infection rates and to explore the role of COVID-19 threat perception on emotional and behavioral responses both cross sectionally and prospectively. METHODS: A community sample (N = 249) was assessed using online crowdsourcing and followed for one month. COVID-19 threat appraisal was compared with actual COVID-19 infection rates and deaths at the time of data collection in each participant's county and state. It was predicted that actual versus perceived COVID-19 infection rates would only be modestly associated. Relative to actual infection rates, perceived infection rates were hypothesized to be a better predictor of COVID-related behaviors, distress, and impairment. RESULTS: Findings indicated that relative to actual infection, perceived infection was a better predictor of COVID-related outcomes cross sectionally and longitudinally. Interestingly, actual infection rates were negatively related to behaviors cross sectionally (e.g., less stockpiling). Prospectively, these variables interacted to predict avoidance behaviors over time such that the relationship between perceived infection and avoidance was stronger as actual infection increased. CONCLUSIONS: These data suggest that perceived COVID-19 infection is significantly associated with COVID-related behaviors, distress and impairment whereas actual infection rates have a less important and perhaps even paradoxical influence on behavioral responses to the pandemic.

COVID-related fear maintains controlling parenting behaviors during the pandemic.

The direct threat posed by the 2019 novel coronavirus (COVID-19), uncertainty surrounding best safety practices, and secondary consequences of the virus have led to widespread stress and declining mental health across communities and individuals. These stresses may impact parenting behaviors, potentially leading to negative consequences for children. Controlling parenting behaviors increase in the face of perceived environmental threat and are associated with adverse mental health outcomes for children; however, determinants of parenting behaviors have not been investigated during the COVID-19 pandemic. The current study prospectively evaluated parenting behaviors during the pandemic (N=87). Results indicated that all negative affect emotions investigated were positively associated with controlling parenting behaviors. However, only COVID-related fear predicted changes in controlling parenting behaviors across timepoints. Specifically, although controlling parenting behaviors decreased in the overall sample from time 1 to time 2, higher COVID-related fear scores at time 1 predicted maintenance of high levels of controlling parenting behaviors at time 2. Additionally, this effect was specific to controlling, as opposed to more adaptive, parenting behaviors. Future studies should investigate the association between parents' COVID-related fear, controlling parenting behaviors, and adverse mental health outcomes for children in the context of the COVID-19 pandemic.

A longitudinal investigation of the association between rumination, hostility, and PTSD symptoms among trauma-exposed individuals.

BACKGROUND: Rumination, defined as perseverative thinking regarding the causes and consequences of psychological symptoms, is a risk and maintaining factor for PTSD. Existing work has largely focused on the extent to which rumination functions as a coping strategy used to avoid traumatic memories and associated emotions. However, rumination may also maintain negative thinking patterns, such as hostility, which has been positively associated with both rumination and PTSD symptoms. The current study therefore investigated the extent to which hostility was a significant mediator of the prospective association between rumination and PTSD symptoms. METHODS: The sample consisted of 119 trauma-exposed individuals (48.7% female), who completed self-report questionnaires at three time points during a clinical trial. RESULTS: When controlling for treatment condition and baseline depressive disorder diagnosis, hostility temporally mediated the effects of rumination on PTSD symptoms. Specificity analyses provided further support for the direction and specific variables examined in this model, such that rumination was positively and uniquely associated with later hostility. LIMITATIONS: Our findings are limited by the use of a sample in which only 30% of participants met diagnostic criteria for a trauma-related disorder, as well as the administration of the rumination measure at only one time point. CONCLUSIONS: Results suggest that rumination and hostility may be promising treatment and prevention targets for PTSD symptoms.

Indices of change in exposure and response prevention for contamination-based OCD.

Few studies have examined indices of change in treatment for obsessive compulsive disorder (OCD). The current study evaluated within- and between-session trajectories of fear, disgust, and urge to wash in exposure and response prevention (ERP) for contamination-based OCD and tested whether change in these indices were associated with treatment outcomes. Forty-one participants (75.6% female) engaged in three sessions of ERP for contamination OCD. Participants provided ratings of fear, disgust, and urge to wash during each session, and contamination symptoms were assessed at pre- and post-treatment and two-week follow-up. Fear, disgust, and urge to wash all significantly decreased both within and between sessions. Both fear and disgust declined significantly faster than urge to wash within session, though declines in fear and disgust did not significantly differ from each other. Within-session changes in fear were significantly associated with reduced symptoms at post-treatment, whereas within-session changes in disgust were associated with symptoms at two-week follow-up. The current study highlights the roles of fear and disgust in the context of ERP as unique indicators of treatment outcome for contamination-based OCD. Only within-session fear was uniquely associated with treatment outcome at post, while within-session disgust predicted outcome at follow-up. Theoretical and clinical implications are discussed.

An investigation of the impact of social exclusion on attachment to possessions and saving behaviors.

BACKGROUND AND OBJECTIVES: Hoarding disorder (HD) is a debilitating mental illness characterized by extreme difficulty parting with possessions and clutter that can result in dangerous living conditions. One hypothesis about why individuals with HD save possessions is that they possess a pathological attachment to their belongings, which may serve to compensate for unfulfilling interpersonal relationships. However, there is a dearth of empirical work examining this. The current study examined the impact of an experimental manipulation of social exclusion on attachment to possessions and saving behaviors in a sample of individuals with elevated hoarding symptoms. METHODS: Participants (n = 117) were selected for scoring above the non-clinical mean on a measure of hoarding symptoms. Participants were randomized to either be included or excluded in a game of Cyberball. They completed a behavioral discarding task and object attachment measure before and after completion of the game. RESULTS: Study condition was unrelated to in vivo attachment to possessions and saving behaviors during the discarding task. However, a post hoc mediation model showed that greater feelings of rejection, regardless of condition, were associated with greater in vivo attachment to possessions and subsequent number of items saved during the lab task. LIMITATIONS: Limitations include the use of a non-clinical and homogeneous sample. CONCLUSIONS: Taken together, individuals prone to feelings of rejection may be at risk for developing HD as they may use possessions to cope with interpersonal stress. Results will be discussed in light of implications for theoretical models and potential treatment targets in HD.

Attachment theory and hoarding disorder: A review and theoretical integration.

Hoarding disorder (HD) is a severe and persistent mental illness characterized by extreme difficulty parting with possessions and considerable clutter that can result in dangerous living conditions. HD poses a considerable public health burden; however, treatment for HD remains relatively limited, as many individuals do not respond to treatment and/or do not maintain treatment gains, suggesting there are important factors not being adequately addressed. In particular, one area that is not well-understood nor well-integrated into cognitive behavioral models is the pathological attachment individuals with HD hold to their possessions. The current review delineates existing work regarding attachment in HD and integrates findings regarding attachment into existing cognitive behavioral models of HD. We use attachment theory as a foundation by which to examine HD and better understand the dysfunctional relationships seen in those who hoard. We propose that both maladaptive cognitions and dysfunctional attachments to people and possessions jointly underlie saving behaviors characteristic of the disorder. The hypotheses put forth in this theory may help to advance our knowledge of HD, identify potential factors that can be targeted in intervention and prevention efforts, and provide important future directions for empirical work.

Epidemiological and Clinical Gender Differences in OCD.

PURPOSE OF REVIEW: This review highlights recent research regarding gender differences in OCD, with a focus on prevalence, course of illness, symptom presentation, comorbidity, and treatment response. RECENT FINDINGS: Overall, findings remain mixed. OCD may be more common among males in childhood, but is more common among females in adolescence and adulthood. Males tend to report an earlier age of onset and present with symptoms related to blasphemous thoughts. Females often describe symptom onset as occurring during or after puberty or pregnancy and present with symptoms related to contamination and/or aggressive obsessions. Females also tend to report significantly higher depression and anxiety. There are no reported gender differences in treatment outcome. Gender may play a role in the onset, presentation, and impact of OCD symptoms. However, more work is needed to account for differences across studies, with one promising future direction being the study of reproductive hormones.

Empirically-derived response trajectories of intensive residential treatment in obsessive-compulsive disorder: A growth mixture modeling approach.

BACKGROUND: This study investigated distinct trajectories of treatment response in a naturalistic intensive/residential treatment (IRT) program for adults with severe obsessive-compulsive disorder (OCD). We hypothesized that: (1) distinct trajectories would emerge and (2) demographic variables, psychiatric comorbidity, OCD symptom subtype, level of insight, previous exposure and response prevention (ERP) treatment, and quality of life, would differentially predict assignment to these trajectories. METHODS: Participants included 305 individuals with primary OCD admitted for IRT. RESULTS: Two trajectories emerged over the course of the first eight weeks of treatment, with the vast majority of participants demonstrating treatment response. The first trajectory (96%, n = 292) showed a negative, linear treatment response (a.k.a. "linear responders") and more severe OCD symptoms at admission. The second trajectory (4%, n = 13) had less severe OCD symptoms at admission and did not exhibit a significant overall change in symptoms over the course of treatment. More specifically, this second trajectory or "u-shaped responders" show a non-significant linear response through week four of treatment, followed by slightly increased symptoms in week five. Assignment to these classes was not differentially predicted by hypothesized predictor variables. LIMITATIONS: Our final model had inconsistent fit indices and small class prevalance of the u-shaped responder group; therefore, model selection was based on both fit indices and substantive meaning. CONCLUSIONS: This study emprically derived two distinct trajectories of OCD symptom severity over the course of IRT. These findings have the potential to refine IRT for patients with severe OCD, and to potentially guide future investigation into the optimal delivery of ERP treatment for OCD generally.

An examination of the relationship between hoarding symptoms and hostility.

Hoarding disorder (HD) is a persistent and severe psychiatric condition in which individuals are unable to discard possessions, which results in considerable clutter. Individuals who hoard often endorse interpersonal difficulties and social isolation. However, little research has examined mechanisms that may help to explain this relationship. One possible mechanism is hostility, which is characterized by increased sensitivity to real or perceived social threats. The current study examined the relationship between hoarding symptoms and hostility across two undergraduate samples. In study 1, unselected undergraduates (N = 195) were administered measures of hoarding symptoms, hostile interpretations, and depression and anxiety symptoms. Participants in study 2 (N = 117) were selected for reporting elevated hoarding symptoms. Study 2 participants were administered the same measures as in study 1, and were additionally randomized to an inclusion or exclusion condition in a social exclusion manipulation. Total hoarding symptoms and hostile interpretations were positively associated across both samples, even when controlling for depression and anxiety. Further, greater hoarding symptoms were associated with increased feelings of hostility in response to social exclusion in study 2. Results suggest that increased sensitivity to social threat may confer risk for hoarding. These findings add to a growing body of research implicating interpersonal factors in the development and maintenance of hoarding disorder.

Mental Contamination in Obsessive-Compulsive Disorder: Associations With Contamination Symptoms and Treatment Response.

The most common symptom of obsessive-compulsive disorder (OCD) is contamination fear. Feelings of contamination can be provoked through contact with a physical contaminant, referred to as contact contamination (CC), as well as in the absence of one, referred to as mental contamination (MC). Prior research indicates that CC and MC are distinct, and MC may interfere with treatment for CC. However, no study to date has examined how MC may be associated with responses to physical contaminants and treatment response for CC. This study examined the relationships between CC and MC in a sample of individuals with elevated contamination symptoms (N = 88), half of whom met diagnostic criteria for OCD. Participants engaged in three sessions of exposure and response prevention (ERP) for CC and completed self-report measures and behavioral tasks assessing CC and MC at pretreatment, posttreatment, and follow-up. As hypothesized, at pretreatment, MC was positively associated with reactivity to physical contaminants, even after participants washed their hands. ERP for CC was associated with unique changes in CC and MC across self-report and behavioral measures, and greater pretreatment MC predicted greater posttreatment CC, though this effect was evident in only one of two CC measures. Additionally, specificity analyses indicated changes in MC were independent of changes in disgust propensity, a related construct. Pretreatment disgust propensity also predicted treatment outcome, though the addition of pretreatment disgust propensity as a covariate reduced the relationship between pretreatment MC and posttreatment CC to nonsignificance. Results suggest MC plays an important role in the manifestation and treatment of CC symptoms and may represent a manifestation of disgust proneness. Theoretical and clinical implications are discussed.

A multi-method analysis of incompleteness in behavioral treatment of contamination-based OCD.

Contamination fear and washing compulsions are among the most common symptoms of obsessive compulsive disorder (OCD). Though these symptoms have traditionally been viewed as being driven by a desire to avoid harm, recent research has highlighted the importance of feelings of incompleteness (INC) or not-just right experiences (NJREs) in this symptom dimension. However, no study to date has examined the extent to which INC/NJREs may be associated with treatment response for contamination symptoms. The current study used a multi-method approach to examine the role of INC/NJREs in treatment of contamination symptoms. Participants (n = 88) with elevated contamination symptoms, half of whom met for an OCD diagnosis, engaged in three sessions of exposure and response prevention (ERP) targeting contamination fears, and completed self-report and in vivo measures of INC/NJRES and contamination symptoms. ERP was associated with significant reductions in INC/NJREs. Further, changes in INC were associated with changes in contamination symptoms, independent of changes in harm avoidance. Greater discomfort in response to an in vivo NJRE task at pre-treatment predicted poor treatment response, though a self-report measure of INC did not predict response. These findings provide novel evidence for the importance of INC/NJREs in contamination-based OCD and its treatment.

Examining the Relationships Between Perfectionism and Obsessive-Compulsive Symptom Dimensions Among Rural Veterans.

Perfectionism, a trait-like individual difference variable reflecting the tendency to set extremely high standards along with critical evaluations of one's own behavior, has long been regarded as a risk and maintenance factor for obsessive-compulsive disorder (OCD). However, research exploring the relationship between these constructs is mixed. One explanation for these equivocal findings is the heterogeneous nature of OCD. Indeed, there is increasing evidence for distinct symptom dimensions that are more homogenous than the broad OCD phenotype. The current study examined the associations between self-reported perfectionism and OCD symptom dimensions controlling for probable depression status. The sample included 67 rural veterans. Results revealed a unique association between perfectionism and the unacceptable thoughts dimension of OCD. These findings are consistent with a growing body of literature demonstrating that OCD symptom dimensions have unique underlying dysfunctional beliefs.

Hoarding symptoms and workplace impairment.

OBJECTIVES: A prior study found that over 50% of treatment-seeking individuals who hoard incur at least one psychiatric work impairment day (i.e., they are unable to work or are less effective at work due to poor mental health) each month. The aim of the current study was to assess work-related variables associated with workplace impairment in a non-treatment-seeking sample. DESIGN: Cross-sectional. Self-report questionnaires were administered via Amazon's Mechanical Turk. METHODS: One hundred and eighty-five employed individuals who reported elevated hoarding symptoms completed questionnaires regarding hoarding symptoms, work engagement, psychiatric work impairment, work control, attention and concentration difficulties at work, and quality of workplace relationships. RESULTS: Greater workplace control and higher quality workplace relationships were associated with greater work engagement. Greater hoarding symptoms and attention difficulties at work were associated with more psychiatric work impairment days. Work engagement statistically mediated the association between the quality of workplace relationships and work impairment, though mediation was also significant when reversing the mediating and outcome variables. CONCLUSIONS: Among a community sample of employed individuals, greater hoarding symptoms were associated with greater psychiatric work impairment. Work-related variables, such as co-worker relationships and attention difficulties, contributed additional variance above that accounted for by hoarding symptoms. There were significant associations between co-worker relationships, work engagement, and workplace impairment, though the direction of the mediation model is unclear. Future research should examine factors associated with unemployment in hoarding disorder. PRACTITIONER POINTS: Clinicians should be aware that greater hoarding severity directly contributes to greater workplace impairment. Clinicians should consider prioritizing the reduction in clutter in living areas that impact one's daily activities and subsequent ability to attend work. Clinicians should assess and treat workplace impairment by helping individuals achieve greater control at work, developing higher quality interpersonal relationships, and improving their attentional abilities.

"Not just right" experiences account for unique variance in eating pathology.

"Not just right" experiences (NJREs) are uncomfortable sensations of incompleteness linked to obsessive-compulsive disorder; however, NJREs may be transdiagnostic and play a role in eating pathology. The current study examined relations between NJREs and eating pathology in undergraduate students. Participants (n = 248) completed self-report and behavioral assessments. Controlling for obsessive-compulsive symptoms, negative affect, and perfectionism, NJRE frequency was associated with greater drive for thinness, body dissatisfaction, and bulimic symptoms. Discomfort in response to a visual in vivo NJRE task was positively associated with drive for thinness and body dissatisfaction. The present study provides initial evidence for NJREs in eating pathology. Theoretical implications are discussed.