Metacognitive therapy versus exposure and response prevention for obsessive-compulsive disorder - A non-inferiority randomized controlled trial.

OBJECTIVE: Exposure with response prevention (ERP) is the first-line treatment for obsessive-compulsive disorder (OCD). However, refusals, dropouts and the required high time and logistic effort constitute barriers to the use of ERP. In a non-inferiority randomized controlled trial, we compared metacognitive therapy (MCT) to exposure with response prevention (ERP) as treatments for OCD. METHOD: 74 outpatients received 12 weekly sessions of either manualized MCT or ERP, with primary outcomes assessed by blinded assessors using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) at pre-treatment, mid-treatment, post-treatment, and 6-month follow-up. Secondary outcomes included measures of depression and anxiety. Non-inferiority margin was specified at no less than d = 0.38 below the improvement reached by ERP, corresponding to a difference of about 3 points on the Y-BOCS. RESULTS: Drop-out rates were low (<14%) and similar in both groups. Linear models indicated non-inferiority of MCT to ERP at post-treatment, but not at 6-month follow-up. While both groups showed comparable Y-BOCS improvements, the MCT group demonstrated a significantly greater reduction in state anxiety scores at post-treatment and follow-up. CONCLUSIONS: Overall, MCT was not inferior to ERP, especially at post-treatment, suggesting it could be a treatment alternative. However, further research is needed to explore differential treatment indications.

A Randomized Controlled Trial of OC-Go for Childhood Obsessive-Compulsive Disorder: Augmenting Homework Compliance in Exposure With Response Prevention Treatment.

The current study investigates a novel digital tool designed to address barriers to out-of-session homework adherence in exposure with response prevention (ERP) for child obsessive-compulsive disorder (OCD). The OC-Go platform allows clinicians to create and push tailored interactive protocol- or symptom-specific assignments to patients on their mobile devices, providing in-the-moment step-by-step directions, encouragement, accountability, and a sense of therapeutic presence for patients during out-of-office exposures. The platform also facilitates objective measurement of homework and allows providers to support one another through a shared and searchable crowdsourced library with hundreds of assignable exposures and psychoeducation activities for specific OCD symptoms. The current study tested the usability and feasibility of the OC-Go platform with ERP stakeholders (OCD therapists, patients, and parents; N = 172) using the System Usability Scale (SUS). The study also tested the efficacy of OC-Go for augmenting homework adherence and clinical response using a randomized controlled, crossover design in a sample of 28 treatment-seeking youth with OCD. Participants randomized to standard ERP exhibited a homework adherence rate of 68.4% (95% CI [65.6, 71.0]), those randomized to ERP with OC-Go exhibited a greater adherence rate of 83.3% (95% CI [80.8, 85.6], p < .001). Both groups experienced large declines in Children's Yale-Brown Obsessive-Compulsive Scale-rated OCD (d = 1.31, p < .001), though participants randomized to begin ERP with OC-Go exhibited clinically significant greater improvement (p = .05), translating into an additional augmented treatment response at the Week 6 primary end point (d = 0.36) and the Week 12 treatment end point (d = 0.72). Stakeholders rated OC-Go in the 90th percentile for usability on the SUS, indicative of a highly usable and easy-to-learn technology. Initial evidence supports OC-Go as a feasible and effective adjunct to improve out-of-office exposure measurement, adherence, and treatment response in ERP for child OCD.

Personalized exposure and experience sampling method feedback versus exposure as usual for obsessive-compulsive disorder: a study protocol for a randomized controlled trial.

BACKGROUND: Patients with obsessive-compulsive disorder (OCD) suffer from repetitive fearful intrusions which they try to neutralize by performing compulsions. OCD is considered to be the most resistant anxiety disorder with a remission rate of only 53% after a year of an evidence-based treatment. Therefore, it remains an obligation to develop and investigate more effective treatment interventions. This study aims to compare personalized exposure with response prevention (ERP) using experience sampling methodology-based feedback to ERP as usual in patients with OCD. Personalized exposure will be provided screen-to-screen in an ecologically valid (real time and real place) context by means of a smartphone application. This app will also be used to collect both objective and subjective data by means of experience sampling methodology (ESM). This ESM data will be used to identify triggers and protective factors for symptom severity, provide personalized feedback and optimize the effect of ERP. The primary goal of this RCT is to compare the effectiveness of personalized ERP to ERP as usual in the traditional context of a therapist's room in patients with OCD in OCD symptom severity, as well as differences in quality of life, depressive symptoms and anxiety states. Since both self-efficacy and experiential avoidance are known to influence symptom severity in OCS, a secondary goal is to examine if a possible treatment effect is mediated by self-efficacy or experiential avoidance. METHODS: This study involves a randomized controlled trial with 20 weekly sessions by 2 groups (ERP as usual versus personalized ERP), repeated measurements at baseline (T0), 5 weeks of treatment (T1), 10 weeks of treatment (T2), 15 weeks of treatment (T3), posttest at 20 weeks (T4), 6 weeks follow-up (T5), 3 months follow-up (T6), 6 months follow-up (T7) and a year follow-up (T8). A hundred and sixty patients with an OCD diagnosis according to DSM-5 criteria will participate. Half of the group will receive exposure with response prevention as usual, the other half will receive personalized exposure with response prevention with a smartphone application and personalized feedback sessions based on experience sampling data. Multilevel mixed modelling analysis will be used to investigate differences in treatment effect, as well as differences in quality of life, depressive symptoms and anxiety states. We will use the macro of Preacher and Hayes and apply bootstrapping methods to assess the possible mediating effect of changes in self-efficacy and experiential avoidance on subsequent treatment effects. DISCUSSION: This randomized controlled trial is the first to assess the influence of delivering ERP through video-calling and the use of an ESM intervention on the symptom severity of OCD. Since the global pandemic COVID-19, the use of video-calling to deliver psychological treatments has become more common, increasing the relevance of this study. TRIAL REGISTRATION: ICTRP Trial NL8254. Registered on 2019-12-24.

Different Psychological Processes in Traditional and ACT-Enhanced ERP for Obsessive-Compulsive Disorder.

Background: Acceptance and commitment therapy (ACT) has been shown to promote willingness to experience intrusive thoughts among individuals with obsessive-compulsive disorder (OCD). Exposure with response prevention (ERP) delivered from an ACT framework (i.e., ACT+ERP) may facilitate changes in how patients relate to their unwanted internal experiences.Aims: Accordingly, the present study aimed to examine the effect of ACT+ERP on appraisals of intrusive thoughts, relative to standard ERP.Methods: Forty-eight adults who received 16 treatment sessions as part of a randomized controlled trial comparing standard ERP to ACT+ERP completed the Interpretation of Intrusions Inventory (III) at pre-treatment, post-treatment, and follow-up.Results: Results showed a significant main effect of time for all III subscales, suggesting that appraisals of intrusive thoughts shift over the course of treatment. The effect of the condition × time interaction, however, differed between the III subscales. Specifically, a significant interaction emerged for the control of thoughts subscale, such that individuals who received ACT+ERP experienced greater reductions in beliefs about the need to control thoughts. The interaction term was not significant for importance of thoughts or responsibility subscales.Conclusions: Findings suggest that augmenting ERP with ACT enhances change in beliefs about the need to control thoughts, but not in beliefs about responsibility and the importance of thoughts. Clinical implications and future research directions will be discussed.

Webcam-Based Online Coaching with Children and Adolescents with Obsessive-Compulsive Disorders - A Single-Case Study.

Objective: Although there is clear evidence-based knowledge regarding state-of-the-art treatment for pediatric obsessive-compulsive disorder (OCD), two main issues remain in clinical practice: (1) Exposure-based cognitive behavioral therapy (CBT) is limited in terms of availability and accessibility or is not adequately provided, and (2) despite large effect sizes of exposure-based CBT, the achieved recovery rates of 50-60 % still show room for improvement. These issues have prompted an increasing focus on delivering exposure-based CBT in new and innovative ways. This study aims to evaluate an intensive therapist-administered online coaching program consisting of exposure with response prevention via video teleconferencing (VTC) as an add-on to weekly outpatient CBT (blended therapy). Method: The blended therapy is examined in n = 5 children and adolescents with OCD using an AB design and multi-informant ratings. Results: This single-case study shows promising results, indicating that a decrease in OCD severity and related functional impairment can be attributed to blended therapy. Moreover, satisfaction with online coaching was high. Conclusions: Despite some principal limitations, the results support the effectiveness and feasibility of blended therapy.

Extended treatment of multimodal cognitive behavioral therapy in children and adolescents with obsessive-compulsive disorder improves symptom reduction: a within-subject design.

BACKGROUND: Based on the current state of research regarding the treatment in pediatric obsessive-compulsive disorder (OCD), cognitive behavioral therapy (CBT) (in severe cases with additional pharmacotherapy) is considered as the first-line treatment according to internationally recognized guidelines. Research is mostly based on randomized controlled trials (RCTs; efficacy research). Thus, examined treatment conditions, especially the treatment duration, and patients' characteristics do not necessarily correspond to those found within routine care. Studies showed CBT packages as a whole to be efficacious, but less is known about the effects of individual CBT components. Furthermore, effects on comorbid symptoms or psychosocial impairment have been often neglected and different rater perspectives have been hardly considered in previous research. METHODS: This effectiveness study aimed to examine the effects of multimodal CBT in children, adolescents, and young adults (age 6-20 years) with OCD (n = 38) within routine care. Effects on obsessive-compulsive and co-existing symptoms were evaluated in a within-subject design by comparing changes during the assessment phase with 12-week standard treatment and with individually tailored extended treatment. Additionally, within the standard treatment, non-exposure treatment was compared to exposure treatment. Multi-informant assessment was applied, and the analyses included multilevel modeling and t-tests for pre-post comparisons. RESULTS: During the standard treatment and extended treatment, obsessive-compulsive symptoms, strain, and functional impairment significantly decreased. Moreover, a significant reduction of overall comorbid symptoms emerged, particularly regarding internalizing symptoms, including anxiety and depression. Comparisons of treatment components indicated that adding exposure with response prevention (ERP) has an additional positive effect. Clinical improvement and remission rates increased considerably when more treatment sessions were provided. CONCLUSIONS: These results suggest that improvement after an initial 12-week course of treatment may not allow for the prediction of non-responders/non-remitters and for the termination of treatment. Overall, the findings show that results from randomized controlled trials are transferrable to routine care. Trial registration number This study was registered retrospectively at the German Clinical Trials Register ( https://drks.de/search/de/trial/DRKS00030050 ).

Internet-based cognitive behavioral therapy in children and adolescents with obsessive-compulsive disorder: A randomized controlled trial.

Objectives: Obsessive-compulsive disorder (OCD) in childhood and adolescence often leads to significant impairment in various areas of life and has a high risk of becoming chronic. Cognitive behavioral therapy (CBT) is the recommended first-line treatment, but it is too rarely implemented in accordance with guidelines and is often not available close to the patient's home. Importantly, internet-based CBT could help to reduce this gap in care. Having previously successfully demonstrated the feasibility of an internet-based CBT approach, we aimed to assess its effectiveness in a waiting list controlled randomized trial. Methods: Children and adolescents aged 6-18 years with a principal diagnosis of OCD received 14 sessions of therapist-delivered CBT via videoconference distributed over 16 weeks. After inclusion, participants were randomly assigned to either the treatment or waiting list group. Participants in the treatment group began treatment immediately after baseline diagnostics, and participants in the waiting list group began treatment after a 16-week waiting period. The primary outcome was a pre-post comparison of OCD symptoms as measured with the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). Additionally, remission was an important outcome measure. Follow-up assessments were conducted for all measures 16 and 32 weeks after completion of treatment. Results: A total of 60 children and adolescents were included into the analyses. Over the course of the treatment, OCD symptoms according to the CY-BOCS significantly decreased in the treatment group compared to the waiting-list control group. Cohen's d between groups was 1.63. After the patients in the waiting list group also received the treatment, the OCD symptoms decreased significantly in this group as well. This improvement of symptoms increased over the course of the follow-up assessments. Remission rate peaked at the 32-week follow-up, with 68% in the treatment group and 79% in the waiting list group. Importantly, patient satisfaction with treatment was high to very high. Conclusion: In our study, OCD symptoms decreased significantly and remission rate was high after internet-based CBT. Those effects were comparable to those found in studies of face-to-face treatment. Although further evidence is needed, these are early indications that our approach may be a viable way to provide access to adequate treatment for children and adolescents affected by OCD. Clinical trial registration: [www.ClinicalTrials.gov], identifier [NCT05037344].

Client's Experiences Using a Location-Based Technology ICT System during Gambling Treatments' Crucial Components: A Qualitative Study.

Cognitive Behavioral Therapy is the treatment of choice for Gambling Disorder (GD), with stimulus control (SC) and exposure with response prevention (ERP) being its two core components. Despite their efficacy, SC and ERP are not easy to deliver, so it is important to explore new ways to enhance patient compliance regarding SC and ERP. The aim of this study is to describe and assess the opinion of two patients diagnosed with problem gambling and GD that used the Symptoms app, a location-based ICT system, during SC and ERP. A consensual qualitative research study was conducted. We used a semi-structured interview, developed ad-hoc based on the Expectation and Satisfaction Scale and System Usability Scale. A total of 20 categories were identified within six domains: usefulness, improvements, recommendation to other people, safety, usability, and opinion regarding the use of the app after completing the intervention. The patients considered the app to be useful during the SC and ERP components and emphasized that feeling observed and supported at any given time helped them avoid lapses. This work can offer a starting point that opens up new research paths regarding psychological interventions for gambling disorder, such as assessing whether location-based ICT tools enhance commitment rates.

Efficacy and cost-effectiveness of therapist-guided internet-delivered behaviour therapy for children and adolescents with Tourette syndrome: study protocol for a single-blind randomised controlled trial.

BACKGROUND: Treatment guidelines recommend behaviour therapy (BT) for patients with Tourette syndrome (TS) and chronic tic disorder (CTD). However, BT is rarely accessible due to limited availability of trained therapists and long travel distances to specialist clinics. Internet-delivered BT has the potential of overcoming these barriers through remote delivery of treatment with minimal therapist support. In the current protocol, we outline the design and methods of a randomised controlled trial (RCT) evaluating an internet-delivered BT programme referred to as BIP TIC. The trial's primary objective is to determine the clinical efficacy of BIP TIC for reducing tic severity in young people with TS/CTD, compared with an active control intervention. Secondary objectives are to investigate the 12-month durability of the treatment effects and to perform a health economic evaluation of the intervention. METHODS: In this single-blind superiority RCT, 220 participants (9-17 years) with TS/CTD throughout Sweden will be randomised to 10-12 weeks of either therapist-supported internet-delivered BT based on exposure with response prevention (BIP TIC) or therapist-supported internet-delivered education. Data will be collected at baseline, 3 and 5 weeks into the treatment, at post-treatment, and 3, 6, and 12 months post-treatment. The primary endpoint is the 3-month follow-up. The primary outcome is tic severity as measured by the Yale Global Tic Severity Scale - Total Tic Severity Score. Treatment response is operationalised as scores of "Very much improved" or "Much improved" on the Clinical Global Impression - Improvement scale, administered at the primary endpoint. Outcome assessors will be blind to treatment condition at all assessment points. A health economic evaluation of BIP TIC will be performed, both in the short term (primary endpoint) and the long term (12-month follow-up). There are no planned interim analyses. DISCUSSION: Participant recruitment started on 26 April 2019 and finished on 9 April 2021. The total number of included participants was 221. The final participant is expected to reach the primary endpoint in September 2021 and the 12-month follow-up in June 2022. Data analysis for the primary objective will commence after the last participant reaches the primary endpoint. TRIAL REGISTRATION: ClinicalTrials.gov NCT03916055 . Registered on 16 April 2019.

Effectiveness of Behaviour Therapy for Children and Adolescents with Tourette Syndrome and Chronic Tic Disorder in a Naturalistic Setting.

It is unclear if the results of randomised controlled trials (RCTs) of behaviour therapy (BT) for Tourette syndrome (TS) and chronic tic disorder (CTD) can be generalised to naturalistic clinical settings and are durable long-term. In this naturalistic study, 74 young people with TS/CTD received BT at a specialist clinic. Data were collected at baseline, post-treatment, and at 3-, 6-, and 12-month follow-ups. Measures included the Yale Global Tic Severity Scale (YGTSS) and the Clinical Global Impression-Improvement scale (CGI-I), amongst others. Tic severity and tic-related impairment improved after treatment, with large within-group effect sizes. At post-treatment, 57% of the participants were classified as treatment responders according to the CGI-I. Tic severity and tic-related impairment improved further through the follow-up, with 75% treatment responders at the 12-month follow-up. BT is an effective and durable treatment for young people with TS/CTD in a naturalistic specialist clinical setting, with comparable effects to RCTs.

Conducting exposure and response prevention treatment for contamination fears during COVID-19: The behavioral immune system impact on clinician approaches to treatment.

The coronavirus disease 2019 (COVID-19) pandemic sparked significant anxiety regarding viral rates and means of transmission. Heightened concerns about contamination have prompted new hygienic strategies to vigilantly guard against infection, including hand washing immediately after touching foreign objects or suspected contaminants. This has presented a critical challenge for the delivery of exposure and response prevention (ERP) therapy to individuals with contamination fears due to Obsessive Compulsive Disorder (OCD), as providers must manage not only their clients' attitudes and reactions but their own as well. In this investigation, self-identified anxiety and OCD treatment specialists (N = 139) provided demographic information, including their anxiety and OCD caseloads, and completed measures related to intolerance of uncertainty (IUS-SF; Carlton et al., 2007), beliefs about exposure therapy (TBES; Deacon et al., 2013), and emotional reactions to physical sensations (The Chills; Maruskin et al., 2012). We tested the hypothesis that intolerance of uncertainty and activation of the behavioral immune system (BIS; Schaller & Park, 2011), a mechanism theoretically activated by the prominent emergence of pathogens to protect against illness would predict attitudes toward exposure. The Chills Scale was used to assess BIS activation, a broad assessment of vasoconstriction responses associated with different emotional reactions, and includes a subscale (coldness) that evaluates vasoconstriction associated with defense against pathogens. Both coldness and OCD caseload, but not anxiety caseload or subscales of intolerance of uncertainty, emerged as significant predictors of clinicians' beliefs about exposure; increases in OCD caseload were also related to decreases in negative beliefs about exposure. Findings are useful in determining methods for aiding clinicians in developing effective approaches to contamination fears during and post-pandemic that include addressing their own BIS-related concerns and mapping out means for social behavioral norms associated with engaging in exposure treatment.

Implementation of internet-delivered cognitive behaviour therapy for pediatric obsessive-compulsive disorder: Lessons from clinics in Sweden, United Kingdom and Australia.

Obsessive-compulsive disorder (OCD) can be successfully treated with cognitive behaviour therapy (CBT). However, as few patients have access to CBT, there is a strong push to develop and evaluate scalable and cost-effective internet-delivered interventions. BIP OCD is a therapist-guided online CBT intervention for pediatric OCD that has shown promise in trials conducted at a single site in Stockholm, Sweden. In this study, we evaluated if BIP OCD is an acceptable, feasible, and effective treatment in other countries and clinical contexts. Thirty-one patients were recruited at three different sites; a specialist OCD clinic in Gothenburg (Sweden), a specialist OCD clinic in London (United Kingdom), and a university-based clinic in Brisbane (Australia). Acceptability and feasibility measures included treatment adherence and feedback from therapists. Clinician assessments were conducted at baseline, post-treatment, and 3-month follow-up. The average module completion for the participants was 8.1/12 (SD = 3.2) and the majority of patients completed the BIP OCD treatment (100% in Gothenburg, and 55.6% in both London and Brisbane). Pooling data from the three sites, the within-group effect sizes from baseline to post-treatment on the Children's Yale-Brown Obsessive-Compulsive Scale were in the expected range (bootstrapped Cohen's d = 1.78; 95% CI 1.18-2.39), with an additional symptom reduction to the 3-month follow-up (bootstrapped Cohen's d = 0.27; 95% CI 0.02-0.51). Participating therapists identified both advantages and difficulties supporting patients in this digital format. The results of this study suggest that the treatment effects obtained in the original BIP OCD trials can be generalized to other clinical contexts nationally and internationally. Lessons learned provide important information for successful implementation of BIP OCD in regular healthcare contexts.

Quality and temporal properties of premonitory urges in patients with skin picking disorder.

Skin picking is a newly recognized obsessive-compulsive spectrum disorder in DSM-5. Similar to some repetitive behaviors in Gilles de la Tourette syndrome (GTS) and obsessive-compulsive disorder (OCD), premonitory urges are assumed to play a critical role in maintaining skin picking behavior, by creating a vicious cycle. The present study is the first to investigate the quality of premonitory urges, as well as the temporal relationship between urges and skin picking behavior in individuals with skin picking disorder. Quality and intensity of premonitory urges was assessed in 15 individuals with skin picking. Urge quality was assessed with the translated University of São Paulo Sensory Phenomena Scale (USP-SPS). Urge intensity was assessed continuously over 20 min using a computer-based tool. Participants were instructed either a) to pick freely or b) to suppress their skin picking behavior. Skin picking events during the free and suppression condition were recorded on video and coded manually. Regarding the types of urges, individuals with skin picking reported mainly physical urge sensations (80%), visual "just-right" feelings (80%), and urge-only sensations (80%) similar to urges reported by GTS and OCD patients. Moreover, the data showed a strong temporal relationship between the intensity of premonitory urges and the emergence of skin picking behavior (R2 = .23) that was weakened when skin picking was suppressed (R2 = .06). The results suggest that skin picking behavior is maintained by premonitory urges and that this vicious cycle of negative reinforcement can be, at least partially, broken by suppressing skin picking behavior.

Exposure and response prevention for obsessive-compulsive disorder: A review and new directions.

Obsessive-compulsive disorder (OCD) is characterized by distressing thoughts and repetitive behaviors that are interfering, time-consuming, and difficult to control. Although OCD was once thought to be untreatable, the last few decades have seen great success in reducing symptoms with exposure and response prevention (ERP), which is now considered to be the first-line psychotherapy for the disorder. Despite these significant therapeutic advances, there remain a number of challenges in treating OCD. In this review, we will describe the theoretical underpinnings and elements of ERP, examine the evidence for its effectiveness, and discuss new directions for enhancing it as a therapy for OCD.

Comorbidity, Parental Psychopathology, and Accommodation in the Treatment of Pediatric Obsessive-Compulsive Disorder: A Case Study.

This article discusses the treatment of a young person with obsessive-compulsive disorder (OCD) characterized primarily by symptoms of physical and mental contamination, as well as religious obsessions. The treatment was complicated by several factors that will be reviewed and addressed. First, this client had a comorbid diagnosis of attention-deficit/hyperactivity disorder. Second, the young client's mother was also diagnosed with OCD and had a significantly anxious presentation. This impacted treatment in two primary ways. One important way treatment was complicated was that the client frequently attempted to manage her mother's emotions by underreporting her own distress at times. The other implication of the mother's diagnosis was that it became difficult to involve her in the treatment of her daughter and reduce her accommodation of her daughter's symptoms. The manner in which these complicating factors were addressed in the successful treatment of this client by adapting evidence-based practice will be presented as a guide for clinicians facing similar challenges.

Utilizing Exposure and Response Prevention to Address Poor Insight in Obsessive-Compulsive Disorder.

Studies indicate that approximately 9%-30% of adults diagnosed with obsessive-compulsive disorder have poor insight into their symptoms. That is, they fail to recognize the excessiveness or irrationality of the obsessive thoughts or their compulsive behaviors. Poor insight in OCD is associated with more severe symptoms, earlier age of illness onset, longer illness duration, and higher rates of comorbid depression. Moreover, some studies have also reported that patients with poor insight are less likely than are those with good or fair insight to respond to first-line treatments such as exposure and response prevention (ERP). Despite the clinical relevance of poor insight, very little research has focused on how to enhance therapy with strategies specifically used to target it. In this report, we use a case study to demonstrate how different techniques can be emphasized or integrated with standard ERP to improve treatment outcomes for this subset of patients.

Computation in Psychotherapy, or How Computational Psychiatry Can Aid Learning-Based Psychological Therapies.

Learning-based therapies, such as cognitive-behavioral therapy, are used worldwide, and their efficacy is endorsed by health and research funding agencies. However, the mechanisms behind both their strengths and their weaknesses are inadequately understood. Here we describe how advances in computational modeling may help formalize and test hypotheses regarding how patients make inferences, which are core postulates of these therapies. Specifically, we highlight the relevance of computations with regard to the development, maintenance, and therapeutic change in psychiatric disorders. A Bayesian approach helps delineate which apparent inferential biases and aberrant beliefs are in fact near-normative, given patients' current concerns, and which are not. As examples, we formalize three hypotheses. First, high-level dysfunctional beliefs should be treated as beliefs over models of the world. There is a need to test how, and whether, people apply these high-level beliefs to guide the formation of lower level beliefs important for real-life decision making, conditional on their experiences. Second, during the genesis of a disorder, maladaptive beliefs grow because more benign alternative schemas are discounted during belief updating. Third, we propose that when patients learn within therapy but fail to benefit in real life, this can be accounted for by a mechanism that we term overaccommodation, similar to that used to explain fear reinstatement. Beyond these specifics, an ambitious collaborative research program between computational psychiatry researchers, therapists, and experts-by-experience needs to form testable predictions out of factors claimed to be important for therapy.

Obsessive-compulsive disorder research: Growing in scope, advances unclear.

There has been impressive growth in scholarly research on obsessive-compulsive disorder (OCD). As a general rule, this can be construed as a sign of health in the subspecialty within anxiety disorder research. One factor that likely contributed to the growth in research on OCD was the observation that obsessional experiences can be placed on a dimension from normal to abnormal (or non-clinical to clinical) (Rachman and de Silva, 1978). While the dramatic growth in OCD research has led to increased sophistication in clinical conceptualization of various presentations of this heterogeneous condition, it has not led to a commensurate increase in the availability of efficacious treatment. This gap, between awareness of the disorder and delivery of evidence-based treatment, serves as a limiting factor in enthusiasm regarding the growth in research productivity on OCD as a sign of health in the subspecialty.

Three-Week Inpatient Treatment of Obsessive-Compulsive Disorder: A 6-Month Follow-Up Study.

Background: Specialized inpatient or residential treatment might be an alternative treatment approach for patients with obsessive-compulsive disorder (OCD) that do not respond satisfactorily to the standard outpatient treatment formats. Method: The aim of this open trial was to investigate the 6-month effectiveness of a 3-week inpatient treatment of OCD, where exposure with response prevention (ERP) was the main treatment intervention. The sample consisted of 187 adult patients with OCD, all with previous treatment attempts for OCD. Results: The sample showed significant reductions in symptoms of OCD and depression. The effect sizes were large for obsessive-compulsive symptoms and moderate to large for depressive symptoms. At discharge, 79.7% of the intent-to-treat (ITT) group were classified as treatment responders (≥35% reduction in Y-BOCS scores). However, some participants experienced relapse, as 61.5% of the ITT group were classified as treatment responders at 6-month follow-up. Antidepressant use appeared not to influence the outcome. Only pre-treatment levels of obsessive-compulsive symptoms emerged as a significant predictor of relapse. Conclusion: The 3-week inpatient programme produced similar treatment effects as previous inpatient and residential studies of longer duration (2 - 3 months). The results suggest that patients with severe OCD can be treated efficiently using this brief inpatient format. However, better relapse prevention interventions are needed.

The temporal relationship between premonitory urges and covert compulsions in patients with obsessive-compulsive disorder.

Recent studies in patients with obsessive-compulsive disorder (OCD) have shown that many compulsions are associated with urges rather than obsessions. Premonitory urges are uncomfortable sensory feelings or a rising inner tension, often likened to the urge to scratch, yawn or blink. We studied premonitory urges preceding mental compulsions in 19 patients with OCD and preceding eye blinks in 16 healthy controls. Urge intensity was assessed continuously over 20 min using a real-time urge intensity monitor; compulsions and blinks were measured as discrete events in a free compulsion/blinking and a compulsion/blink suppression condition. Urge intensity showed an inverted U-shaped relationship (increase then decrease) around compulsions within a time-window of approximately 60 s in patients with OCD and within 13 s around blinks in healthy controls. Urge intensity was higher during compulsion / blink suppression and varied more independently of compulsion execution in patients with OCD. There is a close temporal relationship between premonitory sensations and compulsion execution that changes when compulsions are suppressed, indicating that urge intensity might drive the execution of and is then alleviated by compulsions. Suppression weakens the association between urge intensity and compulsion execution.