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.

Prevalence of bullying in a pediatric sample of body dysmorphic disorder.

Little is known about etiological factors in Body dysmorphic disorder (BDD). Cognitive behavioral and diathesis-stress models have implicated teasing and bullying as significant early environmental stressful triggers. Due to these implications, this study aimed to assess the emergence of BDD in children during early development, and to see if bullying experiences played a role in its development. A total of 219 children ages 7 to 10 were screened for psychopathology. Children were separated into four groups including a BDD group, an OCD group, a clinical control group (consisting of depressive disorders, attention deficit hyperactivity disorder, oppositional defiant disorder, and anxiety disorders not otherwise specified), and a non-clinical control group. Children were given questionnaires to evaluate their bullying and victimization experiences. It was hypothesized that children with BDD would experience more instances of victimization than children with OCD, clinical controls, and non-clinical controls. Contrary to the hypothesis, results indicated that children with BDD symptoms were significantly more likely to be perpetrators of bullying than the other groups [F (3, 27.082) = 17.892, p < .001]. In addition to scoring high on the bullying questionnaires, children with BDD scored high on victim questionnaires as well, suggesting a link between these two peer interpersonal conflicts. The results of this study suggest that bullying behavior might be an unknown characteristic in young children with emerging BDD pathology.

Overvalued ideation in adolescents with obsessive-compulsive disorder.

In Obsessive Compulsive Disorder (OCD), overvalued ideas (OVI) are considered poor prognostic indicators in adults. To date, OVI has not been studied in an adolescent population with OCD, nor has it been examined in relation to obsessive-compulsive beliefs. To investigate the relationship between OVI and specific cognitions, fifty-five adolescents with OCD (35 male; 20 female; age range 13-17 years; M=14.05 years, SD=1.75 years) participated. It was predicted that OVI would be associated with symptom severity and would moderate obsessive-compulsive beliefs and functional disability. Results showed that OVI was associated with symptom severity, but did not moderate the relationship with any OC beliefs or functional domains. To evaluate the role of OVI in treatment outcome, thirteen adolescents completed a cognitive-behavioral treatment program. Severity of their OCD symptoms, OVI, degree of functional impairment and quality of life were assessed. It was expected that all variables would change in response to treatment. Further, it was expected that OVI would mediate treatment outcome for all measures of obsessive-compulsive symptom and belief assessments. Results indicated that there was clinically significant change in symptom severity and functional disability, as well as beliefs regarding responsibility/overestimation of threat. Treatment, assessment, and methodological recommendations for this population are offered.

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.

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.

Compulsive hoarders: how do they differ from individuals with obsessive compulsive disorder?

Hoarding has been considered a subtype of obsessive-compulsive disorder (OCD). Planned revisions to the diagnostic criteria propose that hoarding form a separate diagnosis in a larger category of obsessive compulsive related disorders. To date, there have been few direct comparisons between hoarding and those with other symptoms of OCD. This study builds on work that suggests compulsive hoarding, while similar to OCD, comprises a clinically distinct condition. Three groups were compared: those with OCD without compulsive hoarding symptoms (n=102), those with compulsive hoarding but not OCD (n=21), and individuals who satisfied both criteria (n=25). The groups were compared on obsessionality, compulsivity, overvalued ideas, depression, and anxiety. The two hoarding groups were also compared on hoarding symptoms and savings cognitions. Results indicated that the hoarding-only group reported fewer symptoms than both OCD groups, including fewer obsessions and compulsions and lower depression. Both hoarding groups showed significantly higher overvalued ideas when compared to the OCD-only group. These results suggest that hoarders experience less subjective distress than those with OCD, yet have greater difficulty in challenging dysfunctional cognitions associated with the presenting condition. These findings suggest that individuals with hoarding, whether with or without OCD, will show greater difficulty engaging in cognitive-behavioral interventions.

Status of body dysmorphic disorder in Argentina.

Although body dysmorphic disorder (BDD) has received recent attention, it remains misunderstood and under-studied. The Argentine population seeks out plastic surgery at a disproportionate rate and exhibits high rates of preoccupation with bodily dissatisfaction, yet BDD is unrecognized and research is limited. The current study describes the prevalence, quality of life, and presentation style of BDD in depressed adolescents, as depression is the most common symptom for which adolescents seek treatment in Argentina. Twenty-five depressed adolescents and 85 non-depressed students were initially assessed for depression and BDD and subdivided depending on BDD status. Participants were assessed on various constructs including obsessions and compulsions, overvalued ideas, and overall level of impairment. A 2×2 factorial design was employed, and multivariate analysis of variance (MANOVA) was used to analyze the data. Significant main effects were observed for all dependent measures (BDI, OVIS, YBOCS, and Sheehan Disability Scale) for depressed vs. non-depressed participants and BDD status; significant interactions were observed between independent variables for all dependent measures. Depressed adolescents had significantly higher scores on the YBOCS-BDD, OVIS, BDI, and the Sheehan Disability Scale compared to non-depressed participants; furthermore, individuals reporting BDD symptoms reported significantly higher scores on the YBOCS-BDD, OVIS, BDI, and Sheehan Disability Scale. Significant interactions are discussed according to BDD status and depression on dependent measures. Patients with BDD have poor quality of life and present with anxiety and depression, yet it still remains underdiagnosed.

Methodological issues in the obsessive-compulsive spectrum.

The obsessive-compulsive spectrum is a heterogeneous class of conditions. Recently, expert consensus has emerged regarding possible candidate disorders [Mataix-Cols, D., Petrusa, A., Leckman, J.F., 2007. Issues for DSM-V: How should obsessive-compulsive and related disorders should be classified. American Journal of Psychiatry, 164, 1313-1314]. Further, expert survey data suggest that obsessive-compulsive disorder is composed of overlapping subtypes. However, methodological approaches for testing whether candidate disorders properly belong in the spectrum have varied widely, and do not necessarily differentiate conditions from subtypes. We describe preliminary methodological and statistical recommendations for a systematic approach to determining what constitutes a subtype, how to determine inclusion in the spectrum, and means for ruling out candidate disorders.

Multidimensional body image comparisons among patients with eating disorders, body dysmorphic disorder, and clinical controls: a multisite study.

Body image disturbance is considered a core characteristic of eating disorders and body dysmorphic disorder (BDD), however its definition has been unclear within the literature. This study examined the multidimensional nature of body image functioning among individuals with either anorexia nervosa (AN; n=35), bulimia nervosa (BN; n=26), or BDD (n=56), relative to female (n=34) and male (n=36) psychiatric controls. Participants were recruited from 10 treatment centers in the United States and England and completed psychometrically validated and standardized self-report measures of body image. Overall, the AN, BN, and BDD groups were characterized by significantly elevated disturbances in most body image dimensions relative to their gender-matched clinical controls. There was variability, however, in the comparisons among the three groups of interest, including foci of body dissatisfaction and body image coping patterns. On omnibus indices of body image disturbance and body image quality of life, patients with BDD reported more body image impairment than those with eating disorders. Although AN, BN, and BDD are characterized by body image disturbances, similar and partially distinctive cognitive, behavioral, and emotional elements of body image functioning exist among these groups. The study's empirical and clinical implications are considered.

Skin picking phenomenology and severity comparison.

OBJECTIVE: Despite the substantial distress and impairment often associated with skin picking, there currently is only limited research examining various phenomenological aspects of this behavior. The present research contributes to the existing literature by investigating phenomenological variables related to skin picking, such as family involvement, anxiety, depression, and the emotional consequences of skin picking. Moreover, on the basis of symptom severity level, differences were explored between individuals with skin picking who were from a psychiatric population. METHOD: Forty individuals with various clinician-ascertained DSM-IV diagnoses in addition to skin picking symptomatology participated in the present study, which was conducted from September 2002 through January 2003. Participants were administered a self-report questionnaire (which assessed demographic, symptom, and past diagnostic information) as well as the Beck Depression Inventory, the Beck Anxiety Inventory, and the Self-Injury Interview. RESULTS: Phenomenological data on various aspects of individuals with skin picking are presented. Individuals with mild skin picking and individuals with severe skin picking were compared and found to differ in the level of distress they experienced (t = -2.35, p = .05) and the amount of damage caused by their picking behavior (t = -3.06, p = .01). CONCLUSION: Overall, skin picking represents a behavior with its own unique characteristics and accompanying levels of distress and impairment that warrants specific attention by clinicians.

Social learning theory and cognitive behavioral models of body dysmorphic disorder.

Contemporary cognitive behavioral models of body dysmorphic disorder are reviewed, whereby the first by Neziroglu and colleagues emphasizes conditioning processes and relational frame theory and the latter by Veale emphasizes information processing. A brief review of the existing cognitive behavioral therapy research follows the presentation of the models. The majority of publications on BDD continue to deal with phenomenology and epidemiology, and much more research on cognitive behavioral treatment is needed. Treatment research should be geared towards testing elements of the models explicated in this article, and randomized controlled trials are greatly needed.

Motivation to change as a predictor of treatment response in obsessive compulsive disorder.

BACKGROUND: Motivation to change has been shown to predict treatment outcome in various areas of mental health but has never been examined in obsessive compulsive disorder (OCD). The purpose of this report is to present the first use of the University of Rhode Island Change Assessment (URICA) in an OCD pharmacotherapy sample and to determine whether motivation to change predicts degree of treatment response in this group. METHODS: The sample consisted of 32 outpatients diagnosed with OCD who completed an open-label 10-week trial of fluvoxamine. Participants completed the URICA at baseline. OCD symptom severity was rated at baseline and end of treatment. RESULTS: While overall readiness was not related to change in severity, high scores on the Precontemplation subscale (indicating greater resistance to changing OC behaviors) were associated with less change pre- to post-treatment. CONCLUSIONS: Preliminary findings indicate that greater resistance to change is associated with less improvement in OCD symptom severity following pharmacotherapy. As this is the first use of the URICA as a predictor of OCD response, future research should further examine the role of motivation to change in treatment outcome in a larger OCD sample.

Psychotherapy of obsessive-compulsive disorder and spectrum: established facts and advances, 1995-2005.

Dropout rates and refractory cases persist, for reasons that remain unexplained. There are few predictor variables and few innovative approaches to deal with them. New treatment approaches must be developed to improve treatment response even for the responders. Studies show that symptoms are reduced minimally (30% 50%). No new ways of dealing with treatment-refractory cases have been developed. Studies now include more co-morbid cases, however, and their inclusion may account for some of the lack of progress in improvement rates. It needs to be seen whether patients who have one or more comorbid conditions do as well as patients who do not have comorbidity and whether the number or type of comorbid disorders accounts for treatment response. Perhaps better results would be seen with pure OCD cases. Certainly results now are more generalizable to clinical practice. Now it is important to look for alternative treatment approaches and to apply cognitive therapy to more specific problems. Cognitive therapy seems to be helpful with the disorders of the obsessive-compulsive spectrum. The attrition rate is lower when cognitive therapy is used in the treatment of hypochondriasis, and cognitive therapy also is helpful in reducing OVI , which is more severe in body dysmorphic disorder and hypochondriasis. The role of cognitive therapy in OVI needs further exploration.

Rates of abuse in body dysmorphic disorder and obsessive-compulsive disorder.

Body dysmorphic disorder (BDD) continues to challenge professionals due to symptom severity, co-morbidity, suicidal ideation, and overvalued ideation. Despite the disorder's severity, little research exists. Clinical observation suggests a noteworthy history of abuse; therefore the present study investigated the reported rate of physical, sexual, and emotional abuse in BDD patients. OCD patients were chosen as a comparison group because BDD is considered to be an obsessive-compulsive spectrum disorder. A group survey design was used (N=50 for each group). Results show significantly higher levels of emotional and sexual abuse in the BDD sample versus the OCD sample. No significant differences were found in physical abuse. Abuse may be a contributing factor in BDD, but not in OCD.

Overvalued ideation as a predictor of fluvoxamine response in patients with obsessive-compulsive disorder.

The presence of overvalued ideation (OVI) in patients with obsessive-compulsive disorder (OCD) has been theoretically linked to poorer treatment outcome. OVI has recently been shown to predict treatment outcome in OCD. The purpose of the present study is to determine whether OVI predicts medication treatment response, controlling for initial symptom severity and measurement error. The sample consisted of 34 outpatients diagnosed with OCD who completed an open-label clinical trial of fluvoxamine of 10 weeks' duration. Clinicians administered the Overvalued Ideas Scale (OVIS) at baseline. Symptom severity was rated at baseline and at the end of week 10 using the Yale-Brown Obsessive-Compulsive Scale. Of those who completed the trial, 68% showed a reliable change in obsessions and 62% showed a reliable change in compulsions. Analysis of variance showed that baseline OVIS predicted outcome for obsessions, but not compulsions. A key limitation was the relatively low number of individuals in the upper quartile on the OVIS, thus reducing the predictive power of the measure in relation to treatment outcome. Future research should examine medication treatment outcome with higher scoring patients.

The Children's Yale-Brown Obsessive-Compulsive Scale: item structure in an outpatient setting.

The Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) is one of the most popular measures of symptom severity for childhood obsessive-compulsive disorder (OCD). This study describes the factor structure of the CY-BOCS. A total of 233 children diagnosed with OCD were evaluated with the CY-BOCS. The results indicated that 2 alternate 2-factor solutions (obsessions and compulsions; severity and disturbance) fit the data set best. The results also suggested that items assessing resistance to obsessions and compulsions provide unreliable evaluations of these symptoms in children with OCD. Recommendations for modifications to the CY-BOCS as well as clinical applications and for future research with the measure are made.

Basal ganglia hemorrhagic ablation associated with temporary suppression of obsessive-compulsive symptoms.

Currently, basal ganglia (BG) are considered regulators of motor and emotional activity. It's operationality encompass Obsessive Compulsive Disorder (OCD). The case of a patient suffering with severe OCD is described of note, his symptoms disappeared following a hemorrhage of the left BG. However, once the hemorrhage was reabsorbed his symptoms returned. It is possible that lesions affecting cerebral OCD association circuits may influence the evolution of obsessive-compulsive symptoms.