Changes in harm avoidance and incompleteness across group CBT for OCD and their relationship with symptom change.

BACKGROUND: Obsessive-compulsive disorder (OCD) symptoms are hypothesized to be driven by two core motivations: harm avoidance and incompleteness. While cognitive-behavioural therapy (CBT) is an effective treatment for OCD, many posit that OCD presentations characterized by high incompleteness may be harder to treat. The relationship between the core motivations and treatment outcomes remains to be further explored. AIMS: To investigate if harm avoidance and incompleteness decrease across group CBT and to examine the relationship between treatment outcomes and both baseline and changes in harm avoidance and incompleteness throughout treatment. METHOD: A naturalistic sample of 65 adult out-patients with OCD completed self-report questionnaires measuring OCD symptom severity and the core motivations before, during, and after 12 weeks of group CBT for OCD. RESULTS: Harm avoidance and incompleteness scores significantly decreased from pre- to post-treatment. Pre-treatment harm avoidance and incompleteness levels did not predict post-treatment symptom severity, but changes in the core motivations throughout treatment were significant predictors of treatment outcome. Specifically, reductions in harm avoidance across treatment and reductions in incompleteness early in treatment, were associated with better treatment outcomes. CONCLUSIONS: Participants who completed group CBT for OCD experienced modest reductions in the core motivations thought to maintain OCD symptoms and these changes predicted better outcomes. However, pre-treatment levels of harm avoidance and incompleteness do not appear to moderate treatment outcome.

Gambling Related Cognitive Distortions in Adolescence: Relationships with Gambling Problems in Typically Developing and Special Needs Students.

The present study examined the link between problematic gambling and gambling related cognitions (GRCs) in a large sample of adolescents with (N = 266) and without (N = 1,738) special education needs (SEN) between the ages of 14 and 18 years attending several high schools in eastern central Ontario. The adolescents with SENs were identified as having various learning disorders and/or internalizing and externalizing problems [e.g., attention deficit hyperactivity disorder (ADHD)]. All adolescents completed a self-report questionnaire package that included the GRC Scale (GRCS; Raylu and Oei in Addiction 99:757-769, 2004), as well as measures of problem gambling, negative affect, and ADHD symptomatology. Results showed that adolescents with SEN hold more erroneous beliefs about gambling and had a higher risk of developing problematic patterns of gambling behaviour than their typically developing peers. Moreover, the GRCS subscales were found to be strong predictors of problem gambling among adolescents both with and without SEN, accounting for a substantial amount of the variance even when controlling for the effects of age, gender, ADHD, and negative affect. It is suggested that intervention and prevention programs aimed at adolescent gambling need to give particular attention to those with SEN.

Are gambling related cognitions in adolescence multidimensional?: Factor structure of the Gambling Related Cognitions Scale.

The present study examined the factor structure of the Gambling Related Cognitions Scale (GRCS); (Raylu and Oei in Addiction 99:757-769, 2004) in a large sample of adolescents (N = 1,490) between the ages of 16 and 18 years (630 males, 860 females) attending several high schools in central Ontario. Problem gambling was measured using the DSM-IV-J (Fisher in J Gambl Stud 8:263-285, 1992). A 5-factor GRCS model was found to have the best fit to the data, and gambling-related cognitions were found to be powerful predictors of disordered gambling among adolescents. However, strong associations among GRCS subscales, as well as the small amount of variance in problem gambling accounted for by specific GRCS subscales, call into question the multidimensionality of the GRCS when used with adolescents.

Longitudinal Associations Between Symptoms of ADHD and Life Success: From Emerging Adulthood to Early Middle Adulthood.

OBJECTIVE: To expand on current adult ADHD literature by investigating the stability of ADHD symptomatology (i.e., inattention and hyperactivity-impulsivity) across a 15-year period (from emerging adulthood to early middle adulthood) and the relative contributions of ADHD symptomatology to life success. METHOD: A sample of 320 post-secondary students was initially assessed for ADHD symptomatology using the Conners' Adult ADHD Rating Scale (CAARS). Fifteen years later, participants were re-assessed using the CAARS and several measures of life success (e.g., relationship satisfaction, career satisfaction, and stress levels). RESULTS: Inattention and hyperactivity-impulsivity symptoms showed strong stability across the 15-year period. Additionally, inattention symptoms during emerging adulthood and early middle adulthood were consistently associated with poorer life success (i.e., lower relationship and career satisfaction), particularly for men. Associations for hyperactivity-impulsivity symptoms were less consistent. CONCLUSION: ADHD symptomatology can be conceptualized as a stable, dimensional trait across adulthood, with important impacts on life success.

Gambling behaviour in adolescents with learning disorders.

The present study examined the prevalence of disordered gambling behaviours in a community-based sample of adolescents (N = 532) living in eastern central Ontario. Of particular interest was examining the hypothesis that adolescents with learning disorders are at elevated risk for disordered gambling. Rates of disordered gambling in male adolescents with learning disorders were found to be significantly higher than adolescents without learning problems, even after controlling for negative affectivity and ADHD symptomatology. The implications for treatment and intervention of gambling problems in adolescence are discussed.

ADHD and Academic Success in University Students: The Important Role of Impaired Attention.

OBJECTIVE: To improve on several methodological issues regarding current literature investigating the relationship between ADHD symptomatology and academic success in adults and examine the relative contributions of specific dimensions of ADHD symptomatology (i.e., inattention, hyperactivity, and impulsivity) to post-secondary academic success. METHOD: A large sample of 3,688 post-secondary students were examined using a longitudinal design. The Conners' Adult ADHD Rating Scale (CAARS) was used to assess adult ADHD symptoms and academic success was assessed using students' official academic records (e.g., final GPAs and degree completion status). RESULTS: Students with greater inattention symptomatology at the start of their academic program showed consistently poorer long-term academic success (i.e., lower GPAs, higher dropout rates), regardless of gender. CONCLUSION: Inattention symptoms are the primary driver of the relationship between ADHD symptomatology and academic underachievement in adults. Post-secondary education institutions should target and prioritize educational programming for inattention symptoms of ADHD in at-risk post-secondary students.

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.

A comparison of cluster and factor analytic techniques for identifying symptom-based dimensions of obsessive-compulsive disorder.

A growing body of literature suggests that obsessive-compulsive disorder (OCD) is a heterogeneous condition. The studies investigating symptom dimensions have been limited by numerous methodological differences and sample characteristics. The purpose of this study was to compare the two most commonly applied statistical techniques used in addressing this question in the same large cohort of individuals with OCD. Both cluster analysis and factor analysis were used to examine OCD symptom data as measured by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) Symptom Checklist for 355 individuals with a primary diagnosis of OCD. The factor analysis revealed a three-factor model best described as symmetry obsessions/ordering compulsions, contamination obsessions/cleaning compulsions and aggressive obsessions/checking compulsions. In contrast, the cluster analysis yielded a stable four-cluster solution best described as symmetry obsessions/ordering compulsions, contamination obsessions/cleaning compulsions, aggressive-somatic-religious obsessions/checking compulsions and a mixed symptom profile. Although there was overlap in the models resulting from these two statistical approaches, cluster analysis better captured the dimensional nature of OCD by demonstrating the prevalence of symptom categories in each subgroup. Though both analyses are capable of providing similar outputs, the validity of these results is limited given the input of a priori symptom categories from the Y-BOCS.

Office-based vs home-based behavioral treatment for obsessive-compulsive disorder: a preliminary study.

The current study investigated whether exposure with response prevention (ERP) for obsessive compulsive disorder (OCD) is more effective when administered in a participant's home or other natural environments where symptoms tend to occur, than in a therapist's office. Twenty-eight outpatients with a principal diagnosis of OCD were randomly assigned to receive ERP in their therapist's office vs. wherever their symptoms usually occur (e.g., at home, at work, in public places, in the car, etc.). Participants received 14, 90-min sessions of ERP with an individual therapist. Participants were assessed at pretreatment, post-treatment, and at 3- and 6-month follow-up. Assessments included both self-report as well as clinician-rated indicators of OCD symptom severity, depression, and functional impairment. Results suggested that participants improved significantly, regardless of where treatment occurred. There were no differences in efficacy between the home-based and office-based treatment for OCD. Implications of these findings are discussed.

Why are some obsessions more upsetting than others?

Little is known about why certain obsessional thoughts are more upsetting than others for people with obsessive compulsive disorder (OCD). Obsessional thought content often seems arbitrary to sufferers. The current study examined three possible reasons why particular thoughts would be especially upsetting for individuals, based on suggestions put forth by cognitive theories of obsessional thoughts. Twenty-eight individuals with a principal diagnosis of OCD completed questionnaires and interviews at two different periods of time on (1) their most upsetting current obsession and (2) their least upsetting current obsession. Results suggested that more upsetting obsessions were evaluated as more meaningful or significant than less upsetting obsessions, and more upsetting obsessions contradicted valued aspects of the self to a greater degree. All examples of current obsessions, both most and least upsetting, arose in the context of life concerns or issues. Results support cognitive theories in that the strength and nature of appraisal appears to be linked with the distress associated with a thought, and more upsetting thoughts are those that have implications for a person's sense of self.

Incompleteness, aesthetic sensitivity, and the obsessive-compulsive need for symmetry.

BACKGROUND AND OBJECTIVES: The "need for symmetry" is a well recognized yet little understood feature of obsessive-compulsive (OC) experience. In light of the strong associations between the OC-related trait of incompleteness and symmetry-related behaviors and symptoms, and between perceptual symmetry and aesthetic judgments, this study examined whether trait incompleteness is associated with enhanced natural aesthetic skill and/or aesthetic sensitivity, particularly as they pertain to visual symmetry. METHODS: A quasi-experimental design was used to compare the responses of nonclinical individuals with high versus average levels of trait incompleteness on self-report measures and two performance measures of aesthetic judgment. RESULTS: Compared to controls, participants high in incompleteness reported higher levels of self-perceived symmetry-related concerns and behaviors, and displayed greater aesthetic sensitivity in the form of substantially heightened preferences for symmetry in images. Contrary to the hypothesis relating to aesthetic skill, however, the two groups did not differ in their capacity to estimate accurately the objective aesthetic value of images. Nor did they differ in self-reported aesthetics interests and background. LIMITATIONS: A clinical sample was not included. CONCLUSIONS: Findings provide evidence that high trait incompleteness is associated not just with symptomatic symmetry-related concerns but with a nonspecific heightened preference for visual symmetry. Conceptual implications are discussed, particularly the potential value of the perceptual fluency theory of symmetry and aesthetic response for explaining the association between incompleteness and symmetry preferences and symptoms.

The relationship between miscellaneous symptoms and major symptom factors in obsessive-compulsive disorder.

The diverse symptomatology of obsessive-compulsive disorder (OCD) is being increasingly regarded as reducible to a few symptom dimensions. However, prevailing factor-analytically derived models of symptom structure omit a number of the well-recognized "miscellaneous" symptoms of OCD. This study sought to determine whether miscellaneous OCD symptoms, ascertained by the Yale-Brown Obsessive-Compulsive Scale symptom checklist, could be differentially and reliably predicted by four symptom factors (obsessions and checking, symmetry and ordering, contamination and cleaning, and hoarding) in two independent groups of individuals with OCD (n=381 and n=107). Logistic regression analyses were used to determine the association of each of the miscellaneous symptoms with the symptom factors; then a single confirmatory factor analysis was conducted to test the model of associations in the smaller sample. Sixteen (89%) of the 18 symptoms examined were reliably predicted by one (11 items) or two (5 items) of the factors, with obsessions and checking and symmetry and ordering emerging as foremost predictors. The expanded four-factor model showed good fit with data from the second sample. Results are conceptually meaningful, but suggest the inadequacy of groupings based solely upon overt behaviors. These findings may aid clinical understanding of OCD and be of value to studies using symptom factors to guide investigation of its causes and correlates.

Consistency between self-report and clinician-administered versions of the Yale-Brown Obsessive-Compulsive Scale.

BACKGROUND: Preliminary efforts to demonstrate the utility of a self-rated version of the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) have been promising; however, earlier reports are based on small clinical samples. The objective of the present study was to evaluate the level of agreement between the clinician-administered Y-BOCS and a self-report version. METHODS: Participants included 86 individuals with a principal diagnosis of obsessive-compulsive disorder (OCD). All participants were given the self-report version of the Y-BOCS to complete offsite and instructed to return it at a second assessment session (within a 2-week time frame), at which time a trained and experienced clinician administered the Y-BOCS interview. RESULTS: The two versions were moderately correlated with the highest correlation observed for the Compulsions subscale. Comparison of scores for individual items revealed several inconsistencies between the two measures: level of agreement was low for resistance items, and the interview version generated higher compulsion severity ratings. CONCLUSIONS: The study provided moderate support for the convergence of the self-report and clinician-administered version of the Y-BOCS, however, important difference were detected between the two assessment methods.

Changes in perfectionism following cognitive-behavioral treatment for social phobia.

Previous studies have found that social phobia (social anxiety disorder) is associated with elevated levels of perfectionism, particularly concerns over making mistakes (CM) and doubts about actions (DA). This study investigated the extent to which various dimensions of perfectionism change as a result of participating in a 12-session cognitive-behavioral group treatment for social phobia. One hundred seven individuals completed the Frost Multidimensional Perfectionism Scale before and after treatment. Participants improved on several measures of social anxiety, generalized anxiety, and depression. With respect to perfectionism, significant reductions were seen on total perfectionism scores and scores on particular dimensions (CM, DA, organization), but not on other dimensions (personal standards, parental expectations, parental criticism). Furthermore, changes in DA and to some extent CM predicted posttreatment levels of social anxiety after controlling for pretreatment levels of social anxiety and changes in anxiety and depression. Implications of these findings are discussed.

Understanding and treating incompleteness in obsessive-compulsive disorder.

Incompleteness-the troubling and irremediable sense that one's actions or experiences are not "just right"--appears to underlie many of the symptoms of obsessive-compulsive disorder (OCD). Because incompleteness may reflect basic sensory-affective dysfunction, it presents a challenge to clinicians wishing to apply cognitive-behavioral treatments. In this article, I review ways of adapting well-demonstrated treatment principles to this condition. A case is presented and then used to discuss challenges in conducting cognitive-behavioral therapy with this population. Behavioral methods aimed at habituation (e.g., exposure and ritual prevention [ERP]) are probably more applicable than conventional cognitive techniques. However, even these may result in modest long-term gains; relapse is a probability if they are not actively practiced after treatment cessation.

Preliminary examination of the relationship between anxiety disorders in adults and self-reported history of teasing or bullying experiences.

This preliminary study examined the relationship between anxiety disorders and self-reported history of teasing or bullying experiences, comparing individuals with social phobia, obsessive compulsive disorder, and panic disorder with or without agoraphobia. Given that aversive conditioning experiences, such as severe teasing, have been proposed to play a role in the development of social phobia and that the core feature of social phobia is a fear of social situations in which a person may be embarrassed or humiliated, we hypothesized that the social phobia group would have a higher rate of self-reported teasing history than would the obsessive compulsive disorder or panic disorder groups. Consistent with this hypothesis, a relationship between reported history of teasing and diagnosis was found. A significantly greater percentage of participants in the social phobia group (92%) reported a history of severe teasing experiences compared with the obsessive compulsive disorder (50%) and panic disorder (35%) groups. History of teasing experiences was also significantly related to an earlier age of onset for all 3 anxiety disorders, and to a greater number of self-reported additional problems in childhood. These findings suggest further directions for research in this area and highlight the significant link between perceptions of teasing in childhood and social phobia.

Obsessive-compulsive spectrum conditions in obsessive-compulsive disorder and other anxiety disorders.

In light of current interest in an obsessive-compulsive spectrum of disorders, this study sought to determine whether comorbidity patterns support the unique relationship hypothesized between these conditions and obsessive-compulsive disorder (OCD). Comparisons were made of lifetime rates of several proposed spectrum conditions in individuals with one of three anxiety disorder principal diagnoses (OCD, social phobia, or panic disorder [PD], N=277). Spectrum conditions examined included tic-related disorders, trichotillomania, skin picking, and eating disorders, with analyses performed on rates both of clinical disorder alone, and clinical and subclinical manifestations jointly. The OCD group was found to differ from both other groups in showing 1) a greater proportion of individuals affected with any lifetime spectrum condition, 2) a greater number of lifetime spectrum conditions affecting each individual, and 3) a greater proportion of individuals having a lifetime history of multiple spectrum conditions. Analyses for specific spectrum conditions indicated differences among the anxiety disorder groups for all spectrum categories except eating disorders, though only in the case of tic-related conditions did OCD differ significantly from both comparison groups. For the other conditions, dissimilar patterns of differences were observed among the three groups, particularly when subclinical manifestations were included. These findings have conceptual and clinical implications, including 1) the salience of tic-related disorders in the OC spectrum, 2) the possibility that the relationship between spectrum conditions and anxiety disorders may take several different forms, and 3) the need for refinement of the hypothesized spectrum.