A Short-term Psychological Intervention for People Living with HIV During the First Wave of COVID-19.

Research on the psychosocial impact of COVID-19 has found significant levels of distress among the general population, and among those especially vulnerable due to chronic social or health challenges. Among these are individuals aging with HIV infection, who are encountering COVID-19 as a new infectious threat to their health and wellbeing. In a longitudinal observational study of the psychosocial impact of COVID-19 in middle-aged and older people living with HIV, we identified a subset of participants who expressed heightened levels of distress and were referred for clinical intervention. This paper describes the supportive and contemporary cognitive-behavioral interventions that were provided and presents data on changes in distress in this case series. This work provides a model for identifying people in at-risk groups in acute need of psychological intervention and for implementing an individualized clinical response that can be safely delivered in the context of COVID-19 and future crisis situations.

Introduction to knowledge and competency standards for specialized treatments for obsessive-compulsive disorder throughout the lifespan: Phase two series by the International Accreditation Task Force of the Canadian Institute for Obsessive Compulsive Disorders (CIOCD, www.ciocd.ca).

This paper presents an introduction to the phase two series of papers by the 14 nation International Obsessive-Compulsive Disorders Task Force (ATF) of the Canadian Institute for Obsessive Compulsive Disorders. These papers present evidence-based knowledge and competency standards developed by the ATF for specialized treatments for obsessive-compulsive disorder (OCD) through the lifespan, operationalized as clinician abilities. Specialty standards for OCD do not currently exist and are deemed by experts to be foundational to transformative improvement globally in quality and accessibility of evidence-based treatments for this crippling disorder. Currently available guidelines for care are deemed to be essential but insufficient because of highly variable clinician knowledge and competencies specific to this disorder. The ATF standards encompass specialized cognitive behavior therapy, and pharmacotherapy, for pediatric and adult OCD. Evidence-based methodology with integration of expert opinion are described. Upcoming ATF phases three and four will involve development and implementation of training criteria and processes for certification (individual clinicians) and accreditation (clinical sites) based on the ATF standards. These standards will require periodic review and updating commensurate with advances in clinical research. We hope that this international initiative constitutes a significant step forward to inform and advance evidence-based specialized treatment and training for OCD.

Knowledge and competency standards for specialized cognitive behavior therapy for pediatric obsessive-compulsive disorder.

Although exposure-based cognitive behavior therapy (CBT) and pharmacotherapy have demonstrated efficacy for obsessive-compulsive disorder (OCD), the lack of clinicians effectively trained in these treatments significantly limit effective intervention options for affected youth. This is very unfortunate since child onset is reported by 50% of adults with OCD. To ameliorate this serious global issue the 14 nation International Obsessive-Compulsive Disorders Accreditation Task Force (ATF) of The Canadian Institute for Obsessive Compulsive Disorders (CIOCD) has developed knowledge and competency standards recommended for specialized treatments for OCD through the lifespan. Currently available guidelines are considered by experts to be essential but insufficient because there are not enough clinicians with requisite knowledge and competencies to effectively treat OCD. This manuscript presents knowledge and competency standards recommended for specialized cognitive behavior therapy (CBT) for pediatric OCD, derived from comprehensive literature review and expert synthesis. In addition to standards covering the elements of individual CBT-based assessment and treatment, family and school interventions are addressed given the critical role these domains play in the psychosocial development of youths. The ATF standards presented in these phase two papers will be foundational to the upcoming development of certification (individuals) and accreditation (sites) for specialized treatments in OCD through the lifespan.

Knowledge and competency standards for specialized cognitive behavior therapy for adult obsessive-compulsive disorder.

Obsessive-Compulsive Disorder (OCD) is a leading cause of disability world-wide (World Health Organization, 2008). Treatment of OCD is a specialized field whose aim is recovery from illness for as many patients as possible. The evidence-based psychotherapeutic treatment for OCD is specialized cognitive behavior therapy (CBT, NICE, 2005, Koran and Simpson, 2013). However, these treatments are not accessible to many sufferers around the world. Currently available guidelines for care are deemed to be essential but insufficient because of highly variable clinician knowledge and competencies specific to OCD. The phase two mandate of the 14 nation International OCD Accreditation Task Force (ATF) created by the Canadian Institute for Obsessive Compulsive Disorders is development of knowledge and competency standards for specialized treatments for OCD through the lifespan deemed by experts to be foundational to transformative change in this field. This paper presents knowledge and competency standards for specialized CBT for adult OCD developed to inform, advance, and offer a model for clinical practice and training for OCD. During upcoming ATF phases three and four criteria and processes for training in specialized treatments for OCD through the lifespan for certification (individuals) and accreditation (sites) will be developed based on the ATF standards.

Brain serotonin synthesis capacity in obsessive-compulsive disorder: effects of cognitive behavioral therapy and sertraline.

Cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) are both effective treatments for some patients with obsessive-compulsive disorder (OCD), yet little is known about the neurochemical changes related to these treatment modalities. Here, we used positron emission tomography and the α-[11C]methyl-L-tryptophan tracer to examine the changes in brain regional serotonin synthesis capacity in OCD patients following treatment with CBT or SSRI treatment. Sixteen medication-free OCD patients were randomly assigned to 12 weeks of either CBT or sertraline treatment. Pre-to-post treatment changes in the α-[11C]methyl-L-tryptophan brain trapping constant, K* (ml/g/min), were assessed as a function of symptom response, and correlations with symptom improvement were examined. Responders/partial responders to treatment did not show significant changes in relative regional tracer uptake; rather, in responders/partial responders, 12 weeks of treatment led to serotonin synthesis capacity increases that were brain-wide. Irrespective of treatment modality, baseline serotonin synthesis capacity in the raphe nuclei correlated positively with clinical improvement. These observations suggest that, for some patients, successful remediation of OCD symptoms might be associated with greater serotonergic tone.

Stability and variability of affective experience and interpersonal behavior in borderline personality disorder.

This study examined both mean levels and intraindividual variability in the mood and interpersonal behavior of individuals with borderline personality disorder (BPD) and nonclinical control participants over a 20-day event-contingent recording period. Individuals in the BPD group experienced more unpleasantly valenced affect and were less dominant, more submissive, more quarrelsome, and more extreme in overall levels of behavior than control participants. In addition to these mean-level differences, individuals with BPD also reported more intraindividual variability in overall affect valence and in pleasantly valenced affect; displayed greater variability in dominant, quarrelsome, and agreeable behaviors; and exhibited an increased tendency to "spin" among interpersonal behaviors relative to nonclinical control participants. The findings document behavioral and affective manifestations of BPD in the context of naturally occurring interpersonal situations.

Lack of effects on core obsessive-compulsive symptoms of tryptophan depletion during symptom provocation in remitted obsessive-compulsive disorder patients.

BACKGROUND: Pharmacological evidence support that enhancement of serotonin (5-HT) neurotransmission is critical for treatment efficacy in obsessive-compulsive disorder (OCD). Surprisingly, acute tryptophan depletion (ATD), a procedure known to reduce 5-HT neurotransmission, carried out in remitted OCD patients on selective serotonin reuptake inhibitors (SSRIs) failed to worsen obsessive-compulsive (OC) symptoms. We hypothesized that the putative symptom exacerbation resulting from ATD would only be observed during symptom provocation but not at rest. METHODS: Double-blind placebo-controlled ATD study conducted in 16 OCD patients with stable improvement under either SSRI (n = 8) or specialized cognitive behavior therapy alone (n = 8), coupled with gradual symptom provocation, performed 5 hours after drink ingestion. RESULTS: Acute tryptophan depletion markedly reduced total and free plasma tryptophan levels but did not significantly increase obsessions or compulsions at rest or following symptom provocation. However, subjective distress in response to triggering situations was significantly higher during ATD; significant mood lowering was also present during ATD. CONCLUSIONS: These results are consistent with the view that relapses in OC core symptoms in remitted OCD patients may not depend solely on short-term changes in presynaptic 5-HT availability. In contrast to its apparent lack of effect on core OC symptoms, ATD affected the patient's mood and distress level resulting from provocation.

Do dysfunctional beliefs play a role in all types of obsessive-compulsive disorder?

Some but not all models of obsessive-compulsive disorder (OCD) emphasize the role of dysfunctional beliefs in the etiology and maintenance of this disorder. Clinical observations suggest that some OCD patients have prominent dysfunctional beliefs associated with their obsessions and compulsions, while other patients do not show this pattern. It is possible that dysfunctional beliefs play a role in only a subgroup of cases of OCD and, by extension, that different models might apply to different subtypes of the disorder. To examine this issue, patients with OCD (N = 244) completed measures of dysfunctional OC-related beliefs, along with measures of OC symptoms and demographics. These measures were also completed by three comparison groups; anxious (N = 103), student (N = 284), and community (N = 86) controls. Cluster analysis revealed two OCD clusters: low versus high scores on beliefs (OC-low, OC-high). Belief scores for OC-low were in the range of scores for the comparison groups, which were all significantly lower than those of OC-high. Thus, a cluster of OCD patients was identified who did not have elevated scores on measures of dysfunctional beliefs. OC-low and OC-high did not differ on some OC measures (contamination, checking, grooming), but OC-high had higher scores on measures of harming obsessions. These results are consistent with the view that dysfunctional beliefs may play a role in only some types of OCD.

Specialized psychological and pharmacological treatments for obsessive-compulsive disorder throughout the lifespan: a special series by the Accreditation Task Force (ATF) of The Canadian Institute for Obsessive Compulsive Disorders (CIOCD, www.ciocd.ca).

The World Health Organization ranks obsessive compulsive disorder (OCD) among the leading causes of worldwide medical disability. Affecting approximately 3% of the population, OCD, with its damaging effect on psychosocial function, is among the most severe and impairing of mental disorders. In Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5), OCD and related disorders form a separate classification, consistent with convergent research that indicates OCD is distinct from anxiety disorders in psychopathology and treatment requirements. Although evidence-based treatments have been developed for OCD, these are not accessible to many sufferers. Timely evidence-based treatment is recommended to avoid unnecessary progression to chronicity, disability, and intransigence of symptoms. Improvement in existing training models is needed to disseminate advanced specialty clinical skills to optimize illness recovery. This special series by The Canadian Institute for Obsessive Compulsive Disorders (CIOCD) Accreditation Task Force (ATF) critically reviews evidence-based psychological and pharmacological treatments for OCD throughout the lifespan. The ATF mandate is to establish specialty OCD certification/accreditation standards and competencies. This pioneering initiative aims to achieve transformational change in accessibility to evidence-based clinical care so urgently needed for young people and adults suffering from OCD.

Obsessive-compulsive disorder (OCD): Practical strategies for pharmacological and somatic treatment in adults.

This narrative review gathers together a range of international experts to critically appraise the existing trial-based evidence relating to the efficacy and tolerability of pharmacotherapy for obsessive compulsive disorder in adults. We discuss the diagnostic evaluation and clinical characteristics followed by treatment options suitable for the clinician working from primary through to specialist psychiatric care. Robust data supports the effectiveness of treatment with selective serotonin reuptake inhibitors (SSRIs) and clomipramine in the short-term and the longer-term treatment and for relapse prevention. Owing to better tolerability, SSRIs are acknowledged as the first-line pharmacological treatment of choice. For those patients for whom first line treatments have been ineffective, evidence supports the use of adjunctive antipsychotic medication, and some evidence supports the use of high-dose SSRIs. Novel compounds are also the subject of active investigation. Neurosurgical treatments, including ablative lesion neurosurgery and deep brain stimulation, are reserved for severely symptomatic individuals who have not experienced sustained response to both pharmacological and cognitive behavior therapies.

Cognitive-behavioral therapy for pediatric obsessive-compulsive disorder: Empirical review and clinical recommendations.

The efficacy of cognitive-behavioral therapy (CBT) for pediatric obsessive-compulsive disorder (OCD) has been the subject of much study over the past fifteen years. Building on a foundation of case studies and open clinical trials, the literature now contains many methodologically sound studies that have compared full CBT protocols to waitlist controls, pill placebo, psychosocial comparison conditions, active medication, combined treatments, and brief CBT. This review is part of a series commissioned by The Canadian Institute for Obsessive Compulsive Disorders (CIOCD) in an effort to publish in one place what is known about the efficacy of treatments for OCD. A total of fourteen studies were identified; collectively their findings support the efficacy of CBT for youth with OCD. CBT protocols that emphasized either strictly behavioral or cognitive conceptualizations have each been found efficacious relative to waitlist controls. Efforts to enhance CBT׳s efficacy and reach have been undertaken. These trials provide guidance regarding next steps to be taken to maximize efficacy and treatment availability. Findings from studies in community clinics suggest that significant treatment benefits can be realized and are not reported only from within academic contexts. These findings bode well for broader dissemination efforts. Recommendations for future research directions are provided.

Efficacy of cognitive-behavioral therapy for obsessive-compulsive disorder.

Cognitive-behavioral therapy (CBT), which encompasses exposure with response prevention (ERP) and cognitive therapy, has demonstrated efficacy in the treatment of obsessive-compulsive disorder (OCD). However, the samples studied (reflecting the heterogeneity of OCD), the interventions examined (reflecting the heterogeneity of CBT), and the definitions of treatment response vary considerably across studies. This review examined the meta-analyses conducted on ERP and cognitive therapy (CT) for OCD. Also examined was the available research on long-term outcome associated with ERP and CT. The available research indicates that ERP is the first line evidence based psychotherapeutic treatment for OCD and that concurrent administration of cognitive therapy that targets specific symptom-related difficulties characteristic of OCD may improve tolerance of distress, symptom-related dysfunctional beliefs, adherence to treatment, and reduce drop out. Recommendations are provided for treatment delivery for OCD in general practice and other service delivery settings. The literature suggests that ERP and CT may be delivered in a wide range of clinical settings. Although the data are not extensive, the available research suggests that treatment gains following ERP are durable. Suggestions for future research to refine therapeutic outcome are also considered.

Efficacy of cognitive-behavioral therapy for obsessive-compulsive disorder.

Cognitive-behavioral therapy (CBT), which encompasses exposure with response prevention (ERP) and cognitive therapy (CT), has demonstrated efficacy in the treatment of obsessive-compulsive disorder (OCD). However, the samples studied (reflecting the heterogeneity of OCD), the interventions examined (reflecting the heterogeneity of CBT), and the definitions of treatment response vary considerably across studies. This review examined the meta-analyses conducted on ERP and cognitive therapy (CT) for OCD. Also examined was the available research on long-term outcome associated with ERP and CT. The available research indicates that ERP is the first line evidence based psychotherapeutic treatment for OCD and that concurrent administration of cognitive therapy that targets specific symptom-related difficulties characteristic of OCD may improve tolerance of distress, symptom-related dysfunctional beliefs, adherence to treatment, and reduce drop out. Recommendations are provided for treatment delivery for OCD in general practice and other service delivery settings. The literature suggests that ERP and CT may be delivered in a wide range of clinical settings. Although the data are not extensive, the available research suggests that treatment gains following ERP are durable. Suggestions for future research to refine therapeutic outcome are also considered.

A critical evaluation of obsessive-compulsive disorder subtypes: symptoms versus mechanisms.

Recently, experts have suggested that obsessive-compulsive disorder (OCD), a highly heterogeneous condition, is actually composed of distinct subtypes. Research to identify specific subtypes of OCD has focused primarily on symptom presentation. Subtype models have been proposed using factor analyses that yield dimensional systems of symptom categories, but not necessarily distinct subtypes. Other empirical work has considered the role of neuropsychological functioning and comorbidity as part of a comprehensive scheme for subtyping OCD. The identified dimensions from all of these studies have implications for the treatment of OCD. In this article, we review the research on subtypes of OCD, focusing on subtype schemes based upon overt symptom presentation and neuropsychological profiles. We also review research pertinent to alternative subtyping schemes, both conceptually and methodologically. The research is critically examined and implications for treatment are discussed. Recommendations for future investigations are offered.

Musical obsessions: a comprehensive review of neglected clinical phenomena.

Intrusive musical imagery (IMI) consists of involuntarily recalled, short, looping fragments of melodies. Musical obsessions are distressing, impairing forms of IMI that merit investigation in their own right and, more generally, research into these phenomena may broaden our understanding of obsessive-compulsive disorder (OCD), which is phenomenologically and etiologically heterogeneous. We present the first comprehensive review of musical obsessions, based on the largest set of case descriptions ever assembled (N=96). Characteristics of musical obsessions are described and compared with normal IMI, musical hallucinations, and visual obsessional imagery. Assessment, differential diagnosis, comorbidity, etiologic hypotheses, and treatments are described. Musical obsessions may be under-diagnosed because they are not adequately assessed by current measures of OCD. Musical obsessions have been misdiagnosed as psychotic phenomena, which has led to ineffective treatment. Accurate diagnosis is important for appropriate treatment. Musical obsessions may respond to treatments that are not recommended for prototypic OCD symptoms.

Brain regional α-[11C]methyl-L-tryptophan trapping in medication-free patients with obsessive-compulsive disorder.

CONTEXT: The hypothesis of a serotonin (5-hydroxytryptamine [5-HT]) dysfunction in obsessive-compulsive disorder (OCD) stems largely from the clinical efficacy of 5-HT reuptake inhibitors. Serotonergic abnormalities in the unmedicated symptomatic state, however, remain to be fully characterized. OBJECTIVE: To investigate brain regional 5-HT synthesis, as indexed by positron emission tomography and the α-[(11)C]methyl-L-tryptophan trapping constant (K*), in treatment-free adults meeting criteria for OCD. DESIGN: Between-group comparison. SETTING: Department of Psychiatry and Montreal Neurological Institute, McGill University, and Department of Psychology, McGill University Health Centre, Quebec, Canada. PARTICIPANTS: Twenty-one medication-free patients with OCD (15 men with a mean [SD] age of 33.2 [9.3] years and 6 women with a mean [SD] age of 35.8 [7.1] years) and 21 healthy controls matched for age and sex (15 men with a mean [SD] age of 32.9 [10.1] years and 6 women with a mean [SD] age of 36.5.5 [8.6] years). Main Outcome Measure The α-[(11)C]methyl-L-tryptophan brain trapping constant K*, which was analyzed with Statistical Parametric Mapping (SPM8) and with proportional normalization (extent threshold of 100 voxels with a peak threshold of P ≤ .005). RESULTS: Compared with healthy controls, the patients with OCD exhibited significantly greater α-[(11)C]methyl-L-tryptophan trapping in the right hippocampus and left temporal gyrus (Brodmann area 20). In the larger subsample of all men, these same differences were also evident, as well as higher K* values in the caudate nucleus. Individual differences in symptom severity correlated positively with K* values sampled from the caudate and temporal lobe of the patients with OCD, respectively. There were no regions where the patients exhibited abnormally low K* values. Volumetric analyses found no morphometric alterations that would account for the group differences. CONCLUSION: The results support previous reports of greater striatal and temporal lobe activity in patients with OCD than in healthy controls and suggest that these disturbances include a serotonergic component. Previously reported glucose metabolic disturbances in OCD involving the orbitofrontal and cingulate cortices, in comparison, might reflect postsynaptic changes in the serotonergic system.