Recent advances in the behavioral treatment of obsessive-compulsives.

The last decade has witnessed remarkable progress in the treatment of obsessive-compulsives, with the introduction of response prevention and deliberate exposure to feared situations in vivo and in imagination. In a series of studies, the effects of the single components of this program were investigated. The results suggest that the optimal treatment includes a combination of all three procedures. It appears that in vivo exposure mainly affects anxiety/discomfort associated with cues for ritualizing; response prevention affects primarily compulsive behavior; and imaginal exposure assists in maintenance of treatment gains, perhaps through its impact on fears of future catastrophes associated with obsessions.

Hoarding and emotional reactivity: the link between negative emotional reactions and hoarding symptomatology.

Hoarding disorder (HD) is characterized by difficulty discarding, clutter, and frequently excessive acquiring. Theories have pointed to intense negative emotional reactions (e.g., sadness) as one factor that may play a critical role in HD's etiology. Preliminary work with an analogue sample indicated that more intense negative emotions following emotional films were linked with greater hoarding symptoms. Symptom provocation imaging studies with HD patients have also found evidence for excessive activation in brain regions implicated in processing emotions. The current study utilized a sample with self-reported serious hoarding difficulties to examine how hoarding symptoms related to both general and hoarding-related emotional reactivity, taking into account the specificity of these relationships. We also examined how two cognitive factors, fear of decision-making and confidence in memory, modified this relationship. 628 participants with self-identified hoarding difficulties completed questionnaires about general emotional reactivity, depression, anxiety, decision-making, and confidence in memory. To assess hoarding-related emotional reactivity, participants reported their emotional reactions when imagining discarding various items. Heightened general emotional reactivity and more intense emotional reactions to imagined discarding were associated with both difficulty discarding and acquisition, but not clutter, controlling for age, gender, and co-occurring mood and anxiety symptoms. Fear of decision-making and confidence in memory interacted with general emotional reactivity to predict hoarding symptoms. These findings provide support for cognitive-behavioral models of hoarding. Experimental research should be conducted to discover whether emotional reactivity increases vulnerability for HD. Future work should also examine whether emotional reactivity should be targeted in interventions for hoarding.

DSM-IV and the disappearance of agoraphobia without a history of panic disorder: new data on a controversial diagnosis.

OBJECTIVE: This analysis describes subjects who met rigorous criteria for DSM-III-R agoraphobia without a history of panic disorder and makes inferences from these data regarding relationships among agoraphobia without a history of panic disorder, panic disorder, and panic disorder with agoraphobia. METHOD: Twenty-six subjects (seven men and 19 women) with agoraphobia without a history of panic disorder were identified from among 711 subjects recruited for a multicenter, longitudinal anxiety disorder study. Narrative transcripts prepared by raters from study evaluations were coded for limited symptom attacks, situational panic, catastrophic cognitions, and possible precipitants and stressors, course, and somatic and psychosocial treatments received. RESULTS: Sixty-five percent of the subjects reported experiences consistent with situational panic attacks, and 57% had definite or probable limited symptom attacks; these attacks usually preceded or appeared at the same time as avoidance behavior. Eighty-one percent had catastrophic cognitions associated with agoraphobia. Twenty-six percent reported a likely precipitating factor for symptom onset, and 30% reported a definite or probable major life stressor within 6 months before symptom onset. Cognitive-behavioral treatments were relatively infrequently used. Course was relatively unchanged across the follow-up period. CONCLUSIONS: These data support a view of agoraphobia without a history of panic disorder on a continuum with uncomplicated panic disorder and with panic disorder and agoraphobia, rather than as a separate diagnosis.

Psychiatric complications during flooding therapy for posttraumatic stress disorder.

The authors use six case vignettes to illustrate underrecognized complications occurring during flooding therapy for posttraumatic stress disorder (PTSD), including exacerbation of depression, relapse of alcoholism, and precipitation of panic disorder. A common denominator to the majority of these cases appears to be the mobilization of negative posttrauma appraisal, accompanied by shame, guilt, and anger. The authors suggest that flooding may not be helpful for these negative emotions in the manner that it is for anxiety. Suggestions for preventing and treating complications of flooding therapy for PTSD include employing more cognitive forms of therapy in cases at risk; supporting abstinence from alcohol and other substances; providing adjunctive pharmacologic treatment as indicated, e.g., tricyclics for depression or panic; and providing long-term follow-up.

Utilization of behavioral methods in a multicenter anxiety disorders study.

BACKGROUND: There are abundant data to justify the use of behavioral methods in treating patients with anxiety disorders. Yet there also is evidence that these methods have been underutilized in treating these patients. In this study we examined a large sample of patients with anxiety disorders to determine the extent to which behavior therapy methods were used in their treatment. METHOD: As part of a multicenter longitudinal study of patients with anxiety disorders in New England, we analyzed data pertinent to the type of treatment received by 231 patients at nine study sites. Study subjects received a battery of interview and self-report instruments administered by trained study interviewers at intake and at 6-month follow-up. A Psychosocial Treatments Interview designed by study personnel and administered by study interviewers at 6 months after intake provided data as to types of psychosocial treatment received by study subjects. RESULTS: Behavioral methods were used less frequently than supportive psychotherapy. medication, or psychodynamic psychotherapy. Among behavioral treatments, relaxation and imaginal exposure were used more frequently than in vivo exposure. Obsessive compulsive disorder and agoraphobia without panic were the diagnoses most likely to be treated behaviorally. Behavioral methods were used more frequently in combination with other modalities than they were alone. CONCLUSION: When compared with previous studies, the frequency of utilization of behavioral methods appears to have increased moderately. But our data are still consistent with a pattern of inappropriately low utilization of these effective treatment methods.

Expressed emotion and behavior therapy outcome: a prospective study with obsessive-compulsive and agoraphobic outpatients.

The relationship of expressed emotion (EE) to behavior therapy outcome for obsessive-compulsive disorder (n = 60) and panic disorder with agoraphobia (n = 41) was investigated. Relatives' emotional overinvolvement and hostility predicted higher rates of treatment dropout. Higher hostility, as assessed by the Camberwell Family Interview (CFI), was related to poorer outcome for target ratings and for the Social Adjustment Scale; higher perceived criticism was also predictive of worse response on target ratings. In contrast, nonhostile criticism on the CFI was associated with better outcome on the behavioral avoidance test. In general, the relationship of EE to outcome was not moderated by type of relative, diagnosis, amount of contact with the relative, or use of psychotropic medication.

Measurement of obsessive-compulsive symptomatology: utility of the Hopkins Symptom Checklist.

The Hopkins Symptom Checklist (HSCL) was administered to 62 obsessive-compulsive and 49 nonobsessional patients to examine the reliability and validity of the obsessive-compulsive scale as well as four additional subscales identified in previous research. Test-retest correlation coefficients were generally below acceptable levels. Analyses of construct validity suggested that the obsessive-compulsive scale correlated significantly with other measures of such symptomatology only after treatment when the range of scores was broader than before treatment. The HSCL detected change following treatment on the total score and on four of the five clusters. The obsessive-compulsive scale effectively discriminated obsessive-compulsive patients from other anxious-neurotic patients but a reliable cut-off score that did not misclassify a substantial percentage of patients could not be found.

Effects of imipramine on depression and obsessive-compulsive symptoms.

Most of the controlled studies on the efficacy of medical treatments of obsessive-compulsive disorder (OCD) have involved clomipramine, a tricyclic antidepressant reputed to have anti-obsessional properties. To test the possibility that the drug's antidepressant action mediates the reduction of obsessive-compulsive symptoms, we treated 37 OCD patients with imipramine (mean dose = 233 mg/day) or placebo for 6 weeks and assessed improvement on both obsessive-compulsive and depressive symptoms. Imipramine reduced depression in highly depressed OCD patients, but did not affect obsessive-compulsive symptoms in these or in less depressed patients.

Predictors of course in obsessive-compulsive disorder.

Systematic studies of course of illness in obsessive-compulsive disorder (OCD) using standardized diagnostic criteria are relatively rare. In the present study, 100 patients diagnosed with OCD were prospectively followed for up to 5 years. Other comorbid conditions included anxiety disorders (76%), major depressive disorder (33%), and at least one personality disorder (33%), mainly in the anxious cluster. Approximately 20% of patients had full remission and 50% had partial remission during follow-up. Significant predictors of partial remission included being married and having lower global severity scores at intake; the presence of major depression was marginally predictive of poorer course. Adequate serotonergic medication was associated with worse course, but findings are likely spurious. Only marital status and global severity were retained as predictors in a final regression model. Findings are discussed with regard to sample characteristics and similarity to other reports on predictors of course and of treatment outcome.

The Yale-Brown Obsessive Compulsive Scale: interview versus self-report.

Several studies have demonstrated the reliability and validity of the Yale-Brown Obsessive Compulsive Scale (YBOCS) conducted by trained interviewers. The present study examined several aspects of a self-report YBOCS version relative to the usual interview format in two non-clinical samples (ns = 46 and 70) and in a clinical OCD sample (n = 36) and a clinical non-OCD group (n = 10). The self-rated instrument showed excellent internal consistency and test-retest reliability, performing somewhat better than the interview. There was good agreement between symptom checklist categories across the two versions, though clinical subjects reported more symptoms on the self-report form than on the interview. Some order effects were evident for non-clinical subjects only: those who received the self-report first scored lower on both self-report and interview than those who received the interview first. No order effects were observed in the clinical sample. The self-report version showed strong convergent validity with the interview, and discriminated well between OCD and non-OCD patients. Although more study is needed, particularly on clinical samples, these findings suggest that the self-report YBOCS may be a time-saving and less costly substitute for the interview format in assessing OCD symptoms.

Perfectionism in obsessive-compulsive disorder patients.

Considerable theory and anecdotal evidence has suggested that patients with Obsessive-Compulsive Disorder (OCD) are more perfectionistic. Evidence with non-clinical populations supports this hypothesis. However, no data are available on levels of perfectionism among patients diagnosed with OCD. The present study extends findings on perfectionism and OCD by comparing perfectionism levels of OCD-diagnosed patients with those of non-patients and a group of patients diagnosed with panic disorder with agoraphobia (PDA). As predicted, patients with OCD had significantly elevated scores on Total Perfectionism, Concern Over Mistakes, and Doubts About Actions compared to non-patients controls. However, they did not differ from patients with PDA on Total Perfectionism or Concern Over Mistakes. Patients with OCD did have higher Doubts Actions scores than those with PDA. The implications for role of perfectionism in OCD and other anxiety disorders are discussed.

Reliability and validity of the Yale-Brown Obsessive-Compulsive Scale.

The reliability and validity of the Yale-Brown Obsessive-Compulsive Scale were examined according to a multi-trait multi-method approach in a sample of 54 outpatients with obsessive-compulsive disorder (OCD). Internal consistency was acceptable but was improved by deletion of items concerning resistance to obsessions and compulsions. Inter-rater reliability was excellent, but test-retest reliability over an average interval of 48.5 days was lower than desirable. The YBOCS demonstrated good convergent validity with most other measures of OCD, but divergent validity vis à vis depression was poor. Analyses of new items assessing avoidance and the duration of obsession-free and compulsion-free intervals indicated that only the avoidance rating added meaningfully to the full scale score. In future research the authors recommend deletion of the resistance items and inclusion of the avoidance item to yield a revised 9-item YBOCS total score.

The usefulness of the Obsessive Compulsive Scale of the Symptom Checklist-90-Revised.

The reliability and validity of the SCL-90-R Obsessive Compulsive Scale were examined using a multi-trait multi-method approach in a sample of 54 outpatients with obsessive-compulsive disorder (OCD). The OC scale proved to be internally consistent. Evidence for convergent validity was mixed, and the results suggest poor divergent and criterion-related validities. The scale demonstrated sensitivity to changes with behavioral treatment. Overall, the SCL-90-R proved to be a poor measure of OCD symptoms.

Factor analysis of the English version of the Kategoriensystem für Partnerschaftliche Interaktion [Interaction Coding System].

The Kategoriensystem für Partnerschaftliche Interaktion (KPI), or Interaction Coding System, is an observational coding system used to study behaviors occurring during dyadic interactions. The KPI offers several summary categories (e.g. positive, negative, neutral) to facilitate data analysis, but empirical evidence supporting these rationally derived groupings is lacking. Reported here are the results of a factor analysis of data obtained from 121 spouses or other close relatives of patients with anxiety disorders who participated in dyadic problem-solving interactions with the patients. A three-factor solution accounting for 50% of the variance emerged. The factors were Negativity, Problem-Solving Focus and Emotional Engagement. Confidence in the reliability of the first two factors is bolstered by their similarity to factors detected in prior research on a different coding system, the Marital Interaction Coding System.

Mood, personality disorder symptoms and disability in obsessive compulsive hoarders: a comparison with clinical and nonclinical controls.

Hoarding is a symptom of obsessive compulsive disorder (OCD), as well as a diagnostic criterion for obsessive compulsive personality disorder (OCPD). One recent study suggests that people who suffer from compulsive hoarding report more general psychopathology than people who do not [Frost, R.O., Krause, M.S., & Steketee, G. (1996). Hoarding and obsessive compulsive symptoms. Behavior Modification, 20, 116-132]. The present study addressed whether persons with OCD hoarding exhibit more depression, anxiety, OCD and personality disorders symptoms than community controls, OCD nonhoarders, or other anxiety disorder patients. Disability was also examined. Hoarding subjects were older than the other three groups, but age did not account for any of the differences observed among the groups. Compared to controls, OCD hoarding, nonhoarding OCD and anxiety disorder patients showed elevated YBOCS scores, as well as higher scores on depression, anxiety, family and social disability. Compared to nonhoarding OCD and anxiety disorder patients, OCD hoarding patients scored higher on anxiety, depression, family and social disability. Hoarding subjects had greater personality disorder symptoms than controls. However, OCD hoarding subjects differed from OCD nonhoarding and anxiety disorder subjects only on dependent and schizotypal personality disorder symptoms. The findings suggest that hoarding is associated with significant comorbidity and impairment compared to nonhoarding OCD and other anxiety disorders.

Personality traits in subclinical and non-obsessive-compulsive volunteers and their parents.

Theorists from a variety of perspectives have asserted that obsessive compulsives are more risk-aversive, perfectionistic and guilt-ridden than non-obsessive compulsives, and that these characteristics are central features of the disorder. Furthermore, several have hypothesized that the parents of obsessive compulsives are characterized by risk-aversion, perfectionism, and high levels of criticism. Little research exists which corroborates these hypotheses, however. The present investigation examined these hypotheses among subclinical obsessive compulsives. In two different samples, subclinical obsessive compulsives were found to be more risk-aversive, perfectionistic, and guilt-ridden. Subclinical obsessive compulsives also perceived their parents to be more overprotective. The findings regarding other parental traits were less clear. There was some support for the hypothesis that the parents of subclinical obsessive compulsives are more risk-aversive, and that fathers are more critical and perfectionistic.

Behavioral avoidance test for obsessive compulsive disorder.

Few treatment outcome studies of Obsessive Compulsive Disorder (OCD) have employed Behavioral Avoidance Tests (BATs) to assess changes in symptomatology, probably because of the difficulty of constructing such tests for a disorder which has widely varying symptoms. The few studies that have examined the psychometric properties of BATs for OCD have found mixed evidence for validity but good treatment sensitivity. The present study presents psychometric findings for a multi-step/multi-task BAT that assessed percentage of steps completed, subjective anxiety, global avoidance, and rituals. This measure was used with 50 clients diagnosed with OCD whose symptoms varied widely. The BAT demonstrated good convergent and divergent validity, as well as treatment sensitivity according to effect size calculations. A composite score combining steps, anxiety level, avoidance and rituals also performed well in psychometric tests. Strategies to reduce the complexity of scoring are presented, along with examples of several BAT tasks to enable researchers to employ this behavioral measure.

Hoarding, compulsive buying and reasons for saving.

Two studies examined hypotheses about compulsive hoarding, compulsive buying and beliefs about saving and discarding derived from the cognitive-behavioral model of compulsive hoarding [Frost, R. O. and Hartl, T. (1996). A cognitive behavioral model of compulsive hoarding. Behaviour Research and Therapy, 34, 341-350.]. Study 1 examined the hypotheses in a college student population, while study 2 compared members of a support group for hoarding and clutter-related problems with a nonclinical control. Across studies the hypotheses were supported. Compulsive hoarding was associated with compulsive buying and the frequency of acquisition of possessions discarded by others, suggesting that compulsive acquisition may be a broader construct than compulsive buying among people with hoarding problems. Regarding its association with OCD symptoms, hoarding was most closely associated with the impaired mental control features of OCD. Finally, offa hoarding-related task, hoarding was associated with a greater frequency of reasons to save, but was not associated with fewer reasons to discard a target possession.

Treatment of depressive and obsessive-compulsive symptoms in OCD by imipramine and behaviour therapy.

The efficacy of behavioural treatment of obsessive-compulsive disorder (OCD) has been well documented. However, severely depressed OCD patients showed fewer short- and long-term benefits than less depressed patients. The present study tested the hypothesis that reduction of depression by imipramine prior to behaviour therapy would enhance the effects of behavioural therapy on depressed OC patients. Thirty-eight patients were divided into highly and mildly depressed groups according to their scores on the Beck Depression Inventory; half of each group received imipramine and half received placebo for six weeks. All patients then received three weeks of daily behavioural treatment (exposure and response prevention) followed by 12 weekly sessions of supportive psychotherapy. Results indicated that although imipramine improved depressive symptoms in depressed patients, it did not affect OC symptoms. Behaviour therapy markedly reduced OC symptoms but, contrary to our hypothesis, imipramine did not potentiate the effects of behaviour therapy. No differences between highly depressed and mildly depressed patients on OC symptoms were found in their responses to behavioural or supportive therapy.

Beliefs in obsessive-compulsive disorder.

Several types of beliefs have been hypothesized to be associated with obsessive-compulsive disorder (OCD), including responsibility for harm, need to control thoughts, overestimates of threat, intolerance of uncertainty, and beliefs about the consequences of anxiety and capacity to cope. The present study compared 62 subjects with OCD, 45 with other anxiety disorders (AD) and 34 controls, using 3 measures of OCD-related beliefs. OCD subjects scored higher than AD and control samples on 2 general belief measures. A closer analysis of specific belief domains indicated that OCD subjects scored higher than AD and control subjects on all 6 specific belief domains (responsibility, control, estimation of threat, tolerance of uncertainty, beliefs about the consequences of anxiety, and the capacity to cope). Four of the 6 domains showed reasonable convergent and discriminant validity with measures of OCD symptoms compared to other psychopathology; anxiety and coping beliefs were the exceptions. In regression analyses, cognitive measures contributed significant explanatory power beyond mood state and worry with uncertainty predicting severity of OCD symptoms above all other belief domains. Further research on OCD-relevant belief domains in etiology, maintenance and treatment is warranted.