Sleep Disorders, Sleep Medication Use, and Predictors of Sleep Disturbance in Children with Persistent Tic Disorders.

The present study examined rates of sleep disorders and sleep medication use, and predictors of sleep disturbance in children with persistent tic disorders (PTD). Sixty-three parents of children aged 10 to 17 years with PTDs completed an internet survey evaluating sleep patterns and clinical symptoms. Insomnia (19.4%), nightmares (16.1%), and bruxism (13.1%) were the most commonly reported lifetime sleep disorders. Fifty-two percent endorsed current sleep medication use. Higher ADHD severity, overall life impairment, and female sex predicted greater sleep disturbance. Findings suggest the utility of clinical management of co-occurring ADHD and impairment to mitigate sleep disturbance in children with PTDs.

Sleep and chronotype in adults with persistent tic disorders.

OBJECTIVE: This study examined sleep disorders and sleep medication use rates, nighttime tics, and sleep and chronotype in relation to tic and co-occurring symptoms in adults with persistent tic disorders (PTDs), including Tourette's disorder (TD). METHODS: One hundred twenty-five adult internet survey respondents rated sleep history, sleep, chronotype, tic severity, impairment, attention deficit hyperactivity disorder, obsessive-compulsive symptoms, anxiety, depression, and emotional and behavioral dyscontrol. RESULTS: Bruxism, insomnia, tic-related difficulty falling asleep, and melatonin use were commonly endorsed. Sleep disturbance correlated with impairment, obsessive-compulsive symptoms, and emotional and behavioral dyscontrol. Eveningness correlated with vocal and total tic severity only in TD. Controlling for age and sex, age, impairment, and obsessive-compulsive symptoms predicted sleep disturbance, and age and tic severity predicted chronotype. CONCLUSIONS: Impairment and obsessive-compulsive symptoms play a role in sleep disturbance in adults with PTDs, and may be intervention targets. Eveningness relates to tic severity, which may suggest the utility of interventions to advance chronotype.

Psychometric Properties of the Obsessive Compulsive Inventory-Child Version in Iranian Clinical and Community Samples.

This study evaluated the psychometric properties of the Persian version of the Obsessive-Compulsive Inventory-Child Version (OCI-CV) in clinical and community samples. Factor structure (confirmatory factor analysis), validity (convergent/discriminant, and predictive), and reliability (internal consistency, and 4-week retest) of the Persian version of the OCI-CV were investigated in a sample of 391 children and adolescents 7-17 years comprised of two groups: a clinical sample of youth with OCD (n = 62), and a community sample (n = 329). Participants completed the OCI-CV, Multidimensional Anxiety Scale for Children (MASC), Children's Depression Inventory (CDI), and Child Behavior Checklist (CBCL). Similar to the English version of the OCI-CV, the Persian version of the scale demonstrated a stable six-factor structure, good convergent and discriminant validity through its correlations with other specific measures of pediatric psychopathology, acceptable sensitivity and specificity for the detection of OCD, and good reliability in terms of internal consistency and temporal stability. These findings suggest that the OCI-CV is a valid and reliable measure to assess obsessive-compulsive symptom dimensions in Iranian youth. Findings provide cross cultural support on the utility of OCI-CV as a self-report measure of obsessive-compulsive symptomology.

Morning light therapy in adults with Tourette's disorder.

BACKGROUND: Sleep disturbance is common among individuals with Tourette's Disorder (TD). Given that sleep is influenced by the circadian system, this study examined circadian rhythms and sleep in adults with TD, and explored the possible benefit of short-wavelength wearable morning light therapy. METHODS: Participants were 34 adults with TD (n = 14) and age- and sex-matched healthy controls (HC; n = 20). Participants were screened using clinician-rated diagnostic and tic severity interviews, and procedures lasted 3 consecutive weeks. Participants completed a baseline week of actigraphy. Adults with TD completed 2 weeks of Re-Timer™ morning light therapy and continued actigraphy monitoring. Dim light melatonin-onset (DLMO) phase assessment, tic severity interview, and measures of chronotype, sleep disturbance, daytime sleepiness, disability, depression, anxiety, and stress were completed at baseline and post-intervention. RESULTS: Adults with TD reported significantly greater eveningness and sleep disturbance relative to controls. Per wrist actigraphy, adults with TD exhibited significantly longer sleep-onset latency, lower sleep efficiency, and greater sleep fragmentation than HC. Following morning light therapy, there was a significant advance in DLMO phase, but not self-report or actigraphy sleep variables. There were small, statistically significant decreases in tic severity and impairment. There were also significant reductions in daytime sleepiness, and self-reported anxiety, but not depression, stress, or disability. Participants reported minimal side effects and rated light therapy as acceptable and comfortable. CONCLUSIONS: Findings showed some benefits following brief light therapy in TD; further exploration of the impact of spectral tuning the photic environment as part of treatment for TD subjects is warranted.

Delayed Sleep Timing in Obsessive-Compulsive Disorder Is Associated With Diminished Response to Exposure and Ritual Prevention.

Exposure and ritual prevention (ERP) and pharmacotherapy are typically associated with significant symptom reductions for individuals with obsessive-compulsive disorder (OCD). However, many patients are left with residual symptoms and other patients do not respond. There is increasing evidence that delays in sleep timing/circadian rhythms are associated with OCD but the potential effects of delays in sleep timing on ERP warrant attention. This paper presents data from 31 outpatients with OCD who participated in ERP. Results showed that delayed sleep timing was common and that individuals with delayed bedtimes benefited significantly less from treatment and were significantly more likely to be nonresponders compared to individuals with earlier bedtimes. Further, the effects of sleep timing remained statistically significant even after controlling for global sleep quality, negative affect, and several other variables. These findings add to a growing literature suggesting the utility of better understanding the role of disruptions in the timing of sleep in OCD.

OCD during COVID-19: Understanding clinical and non-clinical anxiety in the community.

The COVID-19 pandemic has created a great deal of anxiety for many individuals. Several papers have noted that individuals with OCD may be particularly negatively impacted by COVID-19, and that the threat of COVID-19 may impact treatment (Banerjee, 2020; Jassi et al., 2020; Sheu et al., 2020). The study presented herein examined OCD-related and COVID-related intrusions in a non-patient sample. Individuals with elevated OCD symptoms reported having both OCD and COVID intrusions at a similar frequency. Further, OCD symptom severity was significantly correlated with the frequency of COVID related intrusions and the amount of distress they caused. However, distress from COVID related intrusions was not significantly correlated with OCD symptom severity. These results shed light on the similarities between reactions to objectively elevated threat and the perceptions of elevated threat experienced in OCD.

Delayed sleep timing and circadian rhythms in pregnancy and transdiagnostic symptoms associated with postpartum depression.

Later sleep timing, circadian preference, and circadian rhythm timing predict worse outcomes across multiple domains, including mood disorders, substance use, impulse control, and cognitive function. Disturbed sleep is common among pregnant and postpartum women. We examined whether sleep timing during third trimester of pregnancy predicted postpartum symptoms of mania, depression, and obsessive-compulsive disorder (OCD). Fifty-one women with a previous, but not active, episode of unipolar or bipolar depression had symptoms evaluated and sleep recorded with wrist actigraphy at 33 weeks of gestation and 2, 6, and 16 weeks postpartum. Circadian phase was measured in a subset of women using salivary dim light melatonin onset (DLMO). We divided the sample into "early sleep" and "late sleep" groups using average sleep onset time at 33 weeks of gestation, defined by the median-split time of 11:27 p.m. The "late sleep" group reported significantly more manic and depressive symptoms at postpartum week 2. Longer phase angle between DLMO and sleep onset at 33 weeks was associated with more manic symptoms at postpartum week 2 and more obsessive-compulsive symptoms at week 6. Delayed sleep timing in this sample of at-risk women was associated with more symptoms of mania, depression, and OCD in the postpartum period. Sleep timing may be a modifiable risk factor for postpartum depression.

Emotion regulation across the psychosis continuum.

Emotion regulation dysfunction is characteristic of psychotic disorders, but little is known about how the use of specific types of emotion regulation strategies differs across phases of psychotic illness. This information is vital for understanding factors contributing to psychosis vulnerability states and developing targeted treatments. Three studies were conducted to examine emotion regulation across phases of psychosis, which included (a) adolescent community members with psychotic-like experiences (PLEs; n = 262) and adolescents without PLEs (n = 1,226); (b) adolescents who met clinical high-risk criteria for a prodromal syndrome (n = 29) and healthy controls (n = 29); and (c) outpatients diagnosed with schizophrenia or schizoaffective disorder (SZ; n = 61) and healthy controls (n = 67). In each study, participants completed the Emotion Regulation Questionnaire and measures of psychiatric symptoms and functional outcome. The three psychosis groups did not differ from each other in reported use of suppression; however, there was evidence for a vulnerability-related, dose-dependent decrease in reappraisal. Across each sample, a lower use of reappraisal was associated with poorer clinical outcomes. Findings indicate that emotion regulation abnormalities occur across a continuum of psychosis vulnerability and represent important targets for intervention.

Later Bedtimes Predict Prospective Increases in Symptom Severity in Individuals with Obsessive Compulsive Disorder (OCD): An Initial Study.

Prior studies of sleep in individuals with OCD have often focused on sleep duration. Several studies have found that individuals with OCD sleep less than healthy controls while others have failed to find significant group differences. Addressing sleep timing has been much more rare, but have consistently shown that many individuals with severe OCD in inpatient facilities had markedly elevated rates of disruptions in sleep timing. We extend prior work by testing prospective relations between sleep and OC symptoms in individuals representing a range of OC symptom severity. Twenty-six individuals diagnosed with OCD, 18 healthy controls, and 10 with subthreshold OC symptoms, completed seven days of sleep diaries and OCD symptom ratings. Results showed that sleep timing (later bedtimes) predicted prospective increases in both obsessions and compulsions in individuals with OCD but not the other two groups. In contrast, there were no significant effects of sleep duration. The significant effects of sleep timing in the OCD group were maintained controlling for depressive symptoms and OCD symptoms did not predict prospective changes in sleep timing. In conclusion, there is increasing evidence that sleep timing may play an important role in OCD and additional work in this area is encouraged.

A systematic review of case studies testing a melatonergic agonist/ 5HT2c antagonist for individuals with obsessive compulsive disorder.

BACKGROUND: Treatments for Obsessive-Compulsive Disorder (OCD) have greatly improved over time. However, some patients do not respond to current interventions and many are left with residual symptoms even if they are 'responders'. There is increasing evidence that individuals with OCD frequently report delayed bedtimes and are at elevated risk for Delayed Sleep Phase Disorder (DSPD). Therefore, it is logical to ask whether interventions addressing disruptions in sleep timing and circadian rhythms would lead to reductions in OCD symptoms. A prior study from our group showed that behaviorally shifting sleep timing resulted in significant symptom reduction in a treatment resistant OCD patient. OBJECTIVES: Extending prior findings, this manuscript presents quantitative data from case studies which tested the use of a pharmacological intervention that targets melatonin receptors. Specifically, the case studies reviewed herein utilized the melatonin analog and melatonergic MT1 and MT2 receptor agonist, Agomelatine. METHODS: A literature review revealed 10 cases which have used Agomelatine for OCD. RESULTS: Seven of the cases were reported to have sleep and/or circadian disruptions prior to treatment. These cases OCD symptom reductions between 46%-90%. In contrast, three additional cases without pre-treatment sleep and/or circadian disruptions did not respond to the intervention. DISCUSSION: There is growing evidence that disruptions in sleep and circadian rhythms may contribute to the maintenance of OCD. Further work is warranted.

Circadian zeitgebers and treatment outcome in inpatient programs for obsessive compulsive disorder (OCD): a pilot study.

High rates of delayed sleep phase disorder have been observed in inpatients with obsessive compulsive disorder (OCD). Up to one-third of patients with OCD do not respond to treatment; therefore, new interventions or methods of enhancing current interventions are imperative. The theory of inpatient circadian care (TICC) posits that enhancing inpatient settings through environmental changes, such as, a set lights out time and consistent scheduling may facilitate symptom improvements in both medical and psychiatric illnesses. Symptom improvements related to these environmental changes have yet to be explored in inpatient and residential OCD treatment program outcomes. Therefore, data on OCD inpatient and residential programs were collected through a meta-analysis conducted by Veale and colleagues (2016). The programs listed in this meta-analysis were contacted to ask follow-up questions regarding their program's scheduling and lights out times. Programs who reported increased consistency in their patients' schedules were significantly more likely to be coded as obtaining treatment response (a post-treatment mean Y-BOCS score <16; X2 = 3.60, p = .05). Further, a Fisher's exact test indicated significant differences, in that 78% of programs with a set lights out time obtained treatment response compared to 0% of programs without a set lights out time. Programs who facilitate set lights out times and consistent schedules may improve treatment response for their patients with OCD, especially for the most severe cases.

Does neuropsychological performance in OCD relate to different symptoms? A meta-analysis comparing the symmetry and obsessing dimensions.

BACKGROUND: Investigations of neuropsychological functioning in obsessive-compulsive disorder (OCD) have produced mixed results for deficits in executive functioning (EF), attention, and memory. One potential explanation for varied findings may relate to the heterogeneity of symptom presentations, and different clinical or neurobiological characteristics may underlie these different symptoms. METHODS: We investigated differences in neuropsychological functioning between two symptoms groups, obsessing/checking (O/C) and symmetry/ordering (S/O), based on data suggesting an association with different motivations: harm avoidance and incompleteness, respectively. Ten studies (with 628 patients) were included and each investigation assessed at least one of 14 neuropsychological domains. RESULTS: The S/O domain demonstrated small, negative correlations with overall neuropsychological functioning, performance in EF, memory, visuospatial ability, cognitive flexibility, and verbal working memory. O/C symptoms demonstrated small, negative correlations with memory and verbal memory performance. A comparison of functioning between symptom groups identified large effect sizes showing that the S/O dimension was more strongly related to poorer neuropsychological performance overall, and in the domains of attention, visuospatial ability, and the subdomain of verbal working memory. CONCLUSIONS: Findings support existing evidence suggesting that different OCD symptoms, and their associated core motivations, relate to unique patterns of neuropsychological functioning, and, potentially dysfunction in different neural circuits.

A Preliminary Investigation of Pathways to Inflated Responsibility Beliefs in Children with Obsessive Compulsive Disorder.

BACKGROUND: Cognitive theorists posit that inflated responsibility beliefs contribute to the development of obsessive compulsive disorder (OCD). Salkovskis et al. (1999) proposed that experiencing heightened responsibility, overprotective parents and rigid rules, and thinking one influenced or caused a negative life event act as 'pathways' to the development of inflated responsibility beliefs, thereby increasing risk for OCD. Studies in adults with OCD and non-clinical adolescents support the link between these experiences and responsibility beliefs (Coles et al., 2015; Halvaiepour and Nosratabadi, 2015), but the theory has never been tested in youth with current OCD. AIMS: We provided an initial test of the theory by Salkovskis et al. (1999) in youth with OCD. We predicted that childhood experiences proposed by Salkovskis et al. (1999) would correlate positively with responsibility and harm beliefs and OCD symptom severity. METHOD: Twenty youth with OCD (age 9‒16 years) completed a new child-report measure of the experiences hypothesized by Salkovskis et al. (1999), the Pathways to Inflated Responsibility Beliefs Scale-Child Version (PIRBS-CV). Youth also completed the Obsessive Beliefs Questionnaire-Child Version (Coles et al., 2010) and the Obsessive Compulsive Inventory-Child Version (Foa et al., 2010). RESULTS: Consistent with hypotheses, the PIRBS-CV was significantly related to responsibility and harm beliefs and OCD symptom severity. CONCLUSIONS: Results provide initial support for the theory proposed by Salkovskis et al. (1999) as applied to youth with OCD. Future studies are needed to further assess the model in early-onset OCD.

Shorter sleep duration and longer sleep onset latency are related to difficulty disengaging attention from negative emotional images in individuals with elevated transdiagnostic repetitive negative thinking.

BACKGROUND AND OBJECTIVES: Repetitive negative thinking (RNT) is often associated with disruptions in sleep and circadian rhythms. Disruptions in sleep and circadian rhythms may deal a "second hit" to attentional control deficits. This study evaluated whether sleep and circadian rhythm disruptions are related to the top-down control of attention to negative stimuli in individuals with heightened repetitive negative thinking. METHODS: Fifty-two community adults with high levels of transdiagnostic RNT and varying habitual sleep durations and bedtimes participated in a hybrid free-viewing and directed attention task using pairs of emotionally-evocative and neutral images while eye-tracking data were collected. Self-report and clinician-administered interviews regarding sleep were also collected. RESULTS: Shorter habitual sleep duration was associated with more time looking at emotionally negative compared to neutral images during a free-viewing attention task and more difficulty disengaging attention from negative compared to neutral images during a directed attention task. In addition, longer sleep onset latencies were also associated with difficulty disengaging attention from negative stimuli. The relations between sleep and attention for positive images were not statistically significant. LIMITATIONS: A causal link between sleep and attentional control cannot be inferred from these cross-sectional data. The lack of a healthy control sample means that the relations between sleep disruption, attention, and emotional reactivity may not be unique to individuals with RNT. CONCLUSIONS: These findings suggest that sleep disruption may be associated with a specific impact on cognitive resources that are necessary for the top-down inhibitory control of attention to emotionally negative information.

Bullying victimization and perpetration in a community sample of youth with psychotic like experiences.

Prior studies indicate an association between psychotic-like experiences (PLEs) and bullying victimization; however, the most frequent types of bullying victimization and the association with bullying perpetration are unclear. A community sample of 1563 adolescents completed questionnaires examining PLEs and frequency of bullying victimization and perpetration. Compared to adolescents scoring below the psychosis-risk cut-off (n=1294), those with PLEs (who are putatively at-risk) (n=269) were more likely to report being the victims of overt, relational, and reputational bullying and to have perpetrated bullying against others. Increased bullying perpetration among youth with PLEs may reflect reactive aggression in response to being bullied.

Sudden gains in exposure therapy for obsessive-compulsive disorder.

Prior research in the treatment of depression and anxiety has demonstrated that a sudden reduction in symptoms between two consecutive sessions (sudden gain) is related to lower post-treatment symptom severity (e.g. Hofmann, Schulz, Meuret, Moscovitch, & Suvak, 2006; Tang & DeRubeis, 1999). However, only one study has examined sudden gains in the treatment of obsessive compulsive disorder (OCD). In that study, one-third of the patients with OCD experienced a sudden gain (Aderka et al., 2012). Further, patients who had a sudden gain had lower clinician-rated OCD symptom severity post-treatment (Aderka et al., 2012). In replication, the current study examined the frequency, characteristics, and clinical impact of sudden gains in 27 OCD patients during exposure and response prevention (ERP) therapy. Fifty two percent of patients experienced a sudden gain. The mean magnitude of a sudden gain represented, on average, 61.4% of total symptom reduction. Following treatment, individuals who had experienced a sudden gain were rated as less severe on the clinical global impression scale, but they did not experience a greater reduction in OCD symptoms (pre-to post-treatment) than those without a sudden gain. None of the pre-treatment characteristics tested were found to significantly predict whether a patient would have a sudden gain. Additional research examining predictors of, and patterns of, change in OCD symptoms is warranted.

Examining heterogeneity of obsessive-compulsive disorder: Evidence for subgroups based on motivations.

Obsessive-compulsive disorder (OCD) is a heterogeneous illness and evidence suggests that different clinical characteristics may relate to varying treatment outcomes. This study was designed to identify subgroups based on core motivational domains in a clinical sample of individuals with OCD, and to compare groups on clinical characteristics. Cluster analyses identified four subgroups including groups with relatively high or low levels of both harm avoidance (HA) and incompleteness (INC) motivations. A subgroup was identified that demonstrated a "traditional profile" marked by high motivation to avoid harm, and elevated levels of beliefs about responsibility/overestimation of threat. The model also contained a subgroup characterized by high incompleteness, low motivation to avoid harm, and higher levels of perfectionistic beliefs and intolerance of uncertainty. Findings reemphasize that current cognitive and behavioral models of OCD may be enhanced by integrating incompleteness/NJREs.

Clinical presentation of not-just right experiences (NJREs) in individuals with OCD: Characteristics and response to treatment.

There is increasing recognition that instead of being motivated by a desire to prevent harm and reduce anxiety, some obsessive-compulsive symptoms may be driven by a desire to get things 'just right' or 'complete' and to reduce a sense of discomfort. However, existing data is largely from non-clinical samples. Therefore, in the current paper we examine the clinical presentation of not just right experiences (NJREs) in patients diagnosed with OCD and compare their experiences to both anxious and unselected controls. Then, we provide preliminary data on NJREs before and after cognitive behavioral therapy (exposure and response prevention). First, individuals with OCD were found to report experiencing significantly more NJREs and being more distressed by them compared to anxious controls and unselected controls. Next, there was some support for the specificity of NJREs to feelings of incompleteness. Finally, we found that after completing treatment, patients reported experiencing significantly less NJREs and experienced less distress associated with the NJREs. In conclusion we believe that more work on the role of NJREs is warranted and that characterizing OCD symptoms as either based on harm avoidance or incompleteness/NJREs may be a useful framework for classifying OCD symptoms.

Initial data on a 5-item measure of OCD symptom severity and change: The obsessive compulsive session change index (OCSCI).

Repeated measurement of symptoms throughout treatment allows providers to assess individual patterns of symptom change. However, outside of a clinical trial, administration of lengthy measures at each session is unlikely. Therefore, in order to bridge the gap between clinical research and actual clinical practice we developed a brief self-report measure of obsessive compulsive symptoms that can be used at each session, the Obsessive Compulsive Session Change Index (OCSCI). The OCSCI assesses time spent on obsessions, time spent on compulsions, interference and distress related to obsessions and compulsions, and relative change in symptoms from the beginning of treatment. This paper reports initial psychometric properties of the OCSCI. Twenty-seven adults receiving exposure and ritual prevention for obsessive compulsive disorder (OCD) completed the OCSCI at each session. Results showed that the OCSCI had good internal consistency, and convergent and divergent validity. Specifically, the OCSCI had moderate to strong correlations with both self-reported and clinician rated OCD. Finally, the OCSCI was not as strongly correlated with depressive symptoms as it was with OCD symptoms. The findings presented herein suggest that the OCSCI can be useful as a measure of client progress throughout treatment.