Investigating an Acceptance and Commitment Therapy-Based Exposure Therapy Intervention in Treatment-Refractory OCD and Related Disorders: Changes in Psychological Flexibility, Treatment Engagement, and Treatment Perceptions.

While exposure therapy is the most effective psychological treatment for obsessive-compulsive disorder (OCD), anxiety, and traumatic stress-related disorders, it is not universally effective, indicating a need for further treatment optimization. This study investigated a shift in approach to exposure therapy with 29 treatment-refractory adults in an OCD clinic not responding to standard treatment, comprising habituation-based exposure therapy. Participants completed standard exposure as a continuation of standard clinic treatment, followed by an acceptance and commitment therapy (ACT) consultation session to assess psychological inflexibility processes interfering with treatment progress, and then an ACT-based exposure targeting behavior change through increasing psychological flexibility. After each exposure, participants and independent raters reported levels of psychological flexibility, rituals, distress, treatment engagement, and treatment perceptions. We observed that the shift to ACT-based exposure was associated with greater psychological flexibility, treatment engagement, treatment acceptability, and treatment preference. These findings suggest that there may be situations where ACT-based exposure has particular utility.

Does the network structure of obsessive-compulsive symptoms at treatment admission identify patients at risk for non-response?

Exposure and response prevention is the gold-standard treatment for obsessive compulsive disorder (OCD), yet up to half of patients do not adequately respond. Thus, different approaches to identifying and intervening with non-responders are badly needed. One approach would be to better understand the functional connections among aspects of OCD symptoms and, ultimately, how to target those associations in treatment. In a large sample of patients who completed intensive treatment for OCD and related disorders (N = 1343), we examined whether differences in network structure of OCD symptom aspects existed at baseline between treatment responders versus non-responders. A network comparison test indicated a significant difference between OCD network structure for responders versus non-responders (M = 0.19, p = .02). Consistent differences emerged between responders and non-responders in how they responded to emotional distress. This pattern of associations suggests that non-responders may have been more reactive to their distress by performing compulsions, thereby worsening their functioning. By examining the association between baseline distress intolerance with other symptom aspects that presumably maintain the disorder (e.g., ritualizing), clinicians can more effectively target those associations in treatment.

Examining depression symptoms within OCD: the role of experiential avoidance.

BACKGROUND: Obsessive compulsive disorder (OCD) and depression commonly co-occur. Past research has evaluated underlying mechanisms of depression in the context of other diagnoses, but few to no studies have done this within OCD. AIMS: This study examines the relationships between distress tolerance (DT), experiential avoidance (EA), depression, and OCD symptom severity across intensive/residential treatment (IRT) for OCD. It was hypothesized that all variables would be significantly moderately related and EA would emerge as a potential contributing factor to change in depression and OCD symptoms across IRT for OCD. METHOD: The sample included 311 participants with a primary diagnosis of OCD seeking IRT. Correlations were performed between all variables at both admission and discharge. A two-step hierarchical regression with change in OCD symptoms and change in DT in the first block and change in EA in the second block examined if change in EA explained change in depression above and beyond change in OCD and DT ability. RESULTS: At both admission and discharge, higher EA, lower DT, and higher OCD symptom severity were significantly associated with more depressive symptoms. Change in EA explained a significant amount of variance in change in depression above and beyond change in OCD symptom severity and change in DT. CONCLUSIONS: This study expands past results within an OCD sample, emphasizing EA as an important treatment target in OCD. Future studies could utilize samples from other treatment contexts, use a measure of EA specific to OCD, and utilize a longitudinal model that takes temporal precedence into account.

Ahead of the Curve: Responses From Patients in Treatment for Obsessive-Compulsive Disorder to Coronavirus Disease 2019.

Alongside concern about the physical health impacts of the coronavirus disease 2019 (COVID-19) crisis, public health officials have also raised concerns about the potential for massive mental health impact. This has led many to wonder, how are individuals with obsessive-compulsive disorder (OCD), and especially those with contamination fears, doing in the era of COVID-19? We present data from eight patients in our residential treatment program for OCD who were admitted prior to any COVID-19 restrictions and continued in treatment at the facility during the pandemic. Much like the general population, our patients varied in the ways they were impacted by COVID-19, yet the majority experienced improvements in OCD symptoms despite the context. This is not to downplay the many ways in which our patients were personally affected by COVID-19. Rather our patients' relatively resilient responses mirror our program's treatment model, which emphasizes exposure and response prevention (ERP) within the complementary framework of acceptance and commitment therapy (ACT). The intention of this article is to challenge the notion that by definition this population will fare worse than the general public or that ERP cannot proceed effectively during this time. In contrast, we underscore that effective OCD treatment can and should continue in the era of COVID-19.

Delayed Bedtimes Are Associated With More Severe Obsessive-Compulsive Symptoms in Intensive Residential Treatment.

Delays in behavioral and biological circadian rhythms (e.g., sleep timing, melatonin secretion) are found more frequently in individuals with severe and treatment-resistant obsessive-compulsive disorder (OCD). In recent years, it has been documented that these delays in behavioral and biological circadian rhythms are associated with more severe OCD symptoms and poorer response to some OCD treatments. This study examined self-reported sleep behaviors in individuals taking part in an intensive treatment for OCD and the relations between these and OCD symptoms (both at admission to and discharge from the treatment program). Replicating previous findings in less severe populations, delayed sleep phases were relatively common in this group and later bedtimes were associated with more severe OCD symptoms at admission. Sleep onset latency and sleep duration were not associated with OCD symptom severity at admission. Later bedtimes were not associated with self-reported depression or worry symptom severity. There was no evidence of sleep behaviors affecting change in OCD symptoms from admission to discharge from treatment-however, later bedtimes at admission were associated with more severe OCD symptoms at admission and discharge from treatment. There was no evidence of sleep onset latency or sleep duration having a similar predictive effect. More severe OCD symptoms at admission were also associated with later bedtimes at admission and discharge from treatment. These bidirectional predictive relations between late bedtimes and OCD symptoms were of small effect size but support the potential value of evaluating sleep timing in individuals with severe and/or treatment-resistant OCD.

Neutral face and complex object neurophysiological processing deficits in long-term schizophrenia and in first hospitalized schizophrenia-spectrum individuals.

BACKGROUND: Face processing is impaired in long-term schizophrenia as indexed by a reduced face-related N170 event-related potential (ERP) that corresponds with volumetric decreases in right fusiform gyrus. Impairment in face processing may constitute an object-specific deficit in schizophrenia that relates to social impairment and misattribution of social signs in the disease, or the face deficit may be part of a more general deficit in complex visual processing. Further, it is not clear the degree to which face and complex object processing deficits are present early in disease course. To that end, the current study investigated face- and object-elicited N170 in long-term schizophrenia and the first hospitalized schizophrenia-spectrum. METHODS: ERPs were collected from 32 long-term schizophrenia patients and 32 matched controls, and from 31 first hospitalization patients and 31 matched controls. Subjects detected rarely presented butterflies among non-target neutral faces and automobiles. RESULTS: For both patient groups, the N170s to all stimuli were significantly attenuated. Despite this overall reduction, the increase in N170 amplitude to faces was intact in both patient samples. Symptoms were not correlated with N170 amplitude or latency to faces. CONCLUSIONS: Information processing of complex stimuli is fundamentally impaired in schizophrenia, as reflected in attenuated N170 ERPs in both first hospitalized and long-term patients. This suggests the presence of low-level visual complex object processing deficits near disease onset that persist with disease course.

Empirically-derived response trajectories of intensive residential treatment in obsessive-compulsive disorder: A growth mixture modeling approach.

BACKGROUND: This study investigated distinct trajectories of treatment response in a naturalistic intensive/residential treatment (IRT) program for adults with severe obsessive-compulsive disorder (OCD). We hypothesized that: (1) distinct trajectories would emerge and (2) demographic variables, psychiatric comorbidity, OCD symptom subtype, level of insight, previous exposure and response prevention (ERP) treatment, and quality of life, would differentially predict assignment to these trajectories. METHODS: Participants included 305 individuals with primary OCD admitted for IRT. RESULTS: Two trajectories emerged over the course of the first eight weeks of treatment, with the vast majority of participants demonstrating treatment response. The first trajectory (96%, n = 292) showed a negative, linear treatment response (a.k.a. "linear responders") and more severe OCD symptoms at admission. The second trajectory (4%, n = 13) had less severe OCD symptoms at admission and did not exhibit a significant overall change in symptoms over the course of treatment. More specifically, this second trajectory or "u-shaped responders" show a non-significant linear response through week four of treatment, followed by slightly increased symptoms in week five. Assignment to these classes was not differentially predicted by hypothesized predictor variables. LIMITATIONS: Our final model had inconsistent fit indices and small class prevalance of the u-shaped responder group; therefore, model selection was based on both fit indices and substantive meaning. CONCLUSIONS: This study emprically derived two distinct trajectories of OCD symptom severity over the course of IRT. These findings have the potential to refine IRT for patients with severe OCD, and to potentially guide future investigation into the optimal delivery of ERP treatment for OCD generally.

Use of an Individual-Level Approach to Identify Cortical Connectivity Biomarkers in Obsessive-Compulsive Disorder.

BACKGROUND: Existing functional connectivity studies of obsessive-compulsive disorder (OCD) support a model of circuit dysfunction. However, these group-level observations have failed to yield neuroimaging biomarkers sufficient to serve as a test for the OCD diagnosis, predict current or future symptoms, or predict treatment response, perhaps because these studies failed to account for the substantial intersubject variability in structural and functional brain organization. METHODS: We used functional regions, localized in each of 41 individual OCD patients, to identify cortical connectivity biomarkers of both global and dimension-specific symptom severity and to detect functional connections that track changes in symptom severity following intensive residential treatment. RESULTS: Global OCD symptom severity was directly linked to dysconnectivity between large-scale intrinsic brain networks-particularly among the dorsal attention, default, and frontoparietal networks. Changes within a subset of connections among these networks were associated with symptom resolution. Additionally, distinct and nonoverlapping cortical connectivity biomarkers were identified that were significantly associated with the severity of contamination/washing and responsibility for harm/checking symptoms, highlighting the contribution of dissociable neural networks to specific OCD symptom dimensions. By contrast, when we defined functional regions conventionally, using a population-level brain atlas, we could no longer identify connectivity biomarkers of severity or improvement for any of the symptom dimensions. CONCLUSIONS: Our findings would seem to encourage the use of individual-level approaches to connectivity analyses to better delineate the cortical and subcortical networks underlying symptom severity and improvement at the dimensional level in OCD patients.

Validating an abbreviated version of the Obsessive Beliefs Questionnaire.

OBJECTIVES: A shorter version of the Obsessive Beliefs Questionnaire (OBQ-44) is needed to promote the use of this measure in research and increase our understanding of cognitive phenomena maintaining obsessive-compulsive disorder (OCD). Additionally, an abbreviated version of the OBQ-44 would encourage frequent monitoring of dysfunctional beliefs in intensive care settings. This study aimed to validate a nine-item version of the questionnaire (OBQ-9). METHOD: Participants seeking intensive/residential treatment for OCD (N = 311) completed relevant measures on a weekly basis and at admission and discharge. RESULTS: A confirmatory factor analysis revealed that the OBQ-9's factor structure replicated the three-factor solution of the OBQ-44. The OBQ-9 demonstrated good psychometric properties and convergent validity and was sensitive to treatment effects. Finally, the OBQ-9 subscales predicted specific OCD dimensions over and above depressive symptoms. CONCLUSION: The OBQ-9 appears to be a psychometrically sound tool for routine outcome monitoring of dysfunctional beliefs in hospital-based settings.

Validation of the distress tolerance scale-short form in obsessive compulsive disorder.

OBJECTIVE: This study aimed to develop and validate the Distress Tolerance Scale-Short Form (DTS-SF), a modification of the original Distress Tolerance Scale, in a severe/complex sample of individuals with obsessive compulsive disorder (OCD). Currently, there are multiple self-report measurements of distress tolerance (DT), highlighting the need for a more refined measure. METHOD: Participants included 222 individuals with a primary diagnosis of OCD (57% male, average age = 31) seeking intensive/residential treatment. Participants completed surveys at admission, discharge, and each week. RESULTS: An exploratory factor analysis revealed a one-factor solution representing overall DT ability. The DTS-SF was found to be sensitive to treatment effects. Appropriate associations between the DTS-SF and other measures were also found, with lower DT associated with greater OCD and depression severity and lower reported quality of life. CONCLUSION: The DTS-SF was found to be a valid and reliable measure with high clinical utility for quickly and accurately measuring DT.

Electrophysiological indicators of inhibitory control deficits in depression.

Ample evidence from behavioral and brain imaging studies suggests that inhibitory control is impaired in depression, though the precise nature of this impairment is unclear. The purpose of the present study was to examine potential deficits in three aspects of inhibitory control - conflict monitoring, conflict resolution, and overt behavioral inhibition - in the context of depressive symptoms. Depressed (n=15) and non-depressed (n=15) participants completed a stop-signal reaction time (SSRT) task while electroencephalography (EEG) data were recorded. EEG results indicate that depression impacts only the conflict resolution phase of inhibitory control, with higher levels of depressive and reflective pondering symptoms associated with poorer conflict resolution. Findings have clear implications for treatments of depression, many of which do not currently target the inhibitory control deficits present in this disorder.

How willing are you? Willingness as a predictor of change during treatment of adults with obsessive-compulsive disorder.

OBJECTIVE: Exposure and response prevention (ERP) is an effective treatment for individuals with obsessive-compulsive disorder (OCD), yet a substantial number of individuals with OCD do not fully respond to this intervention. Based on emerging experimental and clinical research on acceptance, this study sought to explore whether willingness to experience unpleasant thoughts, emotions, and bodily sensations during ERP was associated with improved treatment response. METHODS: Two hundred eighty-eight adults with OCD receiving residential ERP provided self-rated willingness and other exposure-related variables during each daily coached ERP session. Obsessive-compulsive and depressive symptom severity was assessed every week. Multilevel modeling was used to study the impact of willingness on treatment outcome during the first 6 weeks of residential care. RESULTS: Data indicated that individuals with higher willingness during ERP reported faster symptom reduction during residential treatment, even when controlling for length of stay, psychopharmacological intervention, depression, adherence, and rituals performed during ERP. These results appear to have both statistical and clinical significance. CONCLUSIONS: Willingness to fully experience unpleasant and unwanted thoughts, emotions, and bodily sensations during exposures appears to be a marker of successful exposure therapy in adults with OCD. Future research should examine how willingness may enhance extinction learning during ERP.

Cognitive inefficiency in depressive undergraduates: stroop processing and ERPs.

Evidence from neuroimaging studies indicates that depressive symptomatology is associated with inefficient recruitment of prefrontal brain regions while performing tasks that tax executive function. In the current study, we investigated the time-course and ERP signature of inefficient executive functioning using a verbal Stroop color-naming task. Twenty (20) undergraduates with moderate to severe BDI-II depression scores and 20 low-scoring controls completed the task. Performance measures did not differ between the two groups. Overt reaction and P300 latencies indicated that all participants showed prominent Stroop effects, such that incongruent responses were delayed compared to congruent. Effects of task condition on the frontal N450 indicated that depressive participants differentiated congruent and incongruent trials earlier than did controls, and that the size of the congruency effect on the N450 was related to self-reported trait rumination among depressive participants. Following this effect, depressive participants showed larger P300s, suggesting an over-commitment of cognitive control resources in the depressive participants. These data lend further evidence to the cortical inefficiency hypothesis and extend the literature by indicating possible improper timing of neural activations during an executive task in depressive undergraduates.

Electrophysiological indicators of emotion processing biases in depressed undergraduates.

It has been proposed that depressed individuals are biased towards and have more difficulty disengaging from negative information once it has been made salient (e.g. Joormann, J., 2004. Attentional bias in dysphoria: the role of inhibitory processes. Cognition & Emotion 18 (1), 125-147). The current study examined whether attention- and inhibition-related brain potentials were sensitive to both of these phenomena in depression using an affective go/no-go paradigm. Eighteen undergraduates who scored high on the Inventory to Diagnose Depression (IDD; Zimmerman, M., Coryell, W., 1987. The inventory to diagnose depression (IDD): a self-report scale to diagnose major depressive disorder. Journal of Consulting and Clinical Psychology 55 (1), 55-59) and 19 who scored low on the IDD completed the experiment. Results indicated that across all trials, subjects high on depressive symptomatology exhibited larger P3s in response to negative compared to positive stimuli. Examination of ERPs on trials uncontaminated by task-switching effects revealed larger N2s on "no-go" than "go" trials, and, specific to the depressive group, larger N2s in response to positive compared to negative stimuli. These data provide electrophysiological evidence that depressive subjects differentially categorize positive and negative emotional pictures. The P3 valence effect may help to explain difficulties inhibiting negative information seen in depression.

Electrophysiological correlates of decreasing and increasing emotional responses to unpleasant pictures.

We examined event-related brain potential (ERP) modulations during the anticipation and processing of unpleasant pictures under instructions to cognitively decrease and increase negative emotion. Instructions to decrease and increase negative emotion modulated the ERP response to unpleasant pictures in the direction of emotional intensity beginning around 400 ms and lasting several seconds. Decrease, but not increase, instructions also elicited enhanced frontal negativity associated with orienting and preparation prior to unpleasant picture onset. Last, ERP modulation by unpleasant pictures began around 300 ms, just prior to regulation effects, suggesting that appraisal of emotion occurs before emotion regulation. Together, the current findings underscore the utility of ERPs in illuminating the time course of emotion modulation and regulation that may help to refine extant theoretical models.

Modulations of the electrophysiological response to pleasant stimuli by cognitive reappraisal.

Research indicates that individuals successfully regulate their emotions to negatively valenced stimuli using cognitive, antecedent-focused techniques (cf. Gross, 1998). Event-related potential studies have elucidated candidate neural correlates, particularly modulations of the late positive potential (LPP) to index emotion regulation processes. The present study attempted to extend prior demonstrations of emotion regulation effects on the LPP to the domain of positively valenced stimuli. Twenty participants completed a blocked emotion regulation task: The first block consisted of passively viewing pleasant and neutral pictures, whereas the last two blocks consisted of either decreasing or increasing emotions to pleasant pictures. Results replicated our previous findings with negatively valenced stimuli, demonstrating an attenuated LPP during decrease instructions and no effect of increase instructions. Modulation of the ERP as a function of instruction was most prominent during the positive-going slow-wave time window of the LPP, indicating that attentional resources allocated to the perceptual processing of pleasant stimuli may be manipulated using emotion regulation strategies.