The COGINS: A New Measure of Cognitive Insight in Obsessive-Compulsive and Related Disorders.

Research suggests that individuals with obsessive-compulsive and related disorders (OCRDs) with lower insight show a poorer response to cognitive behavioral therapy and might benefit from alternative treatments. However, there are inconsistencies in the literature regarding the definition and measurement of insight. This study endeavored to evaluate the psychometric properties of the Cognitive Obsessional Insight Scale (COGINS), a novel self-report measure of cognitive insight in OCRDs. The sample comprised 166 participants with a diagnosis of obsessive-compulsive disorder or body dysmorphic disorder enrolled in clinical trials. Participants completed the COGINS and a questionnaire battery at baseline and posttreatment. The COGINS demonstrated good internal consistency, test-rest reliability, convergent validity with other OCRD-specific measures of insight, positive associations with OCRD symptomatology, and had a moderating effect on treatment response. The COGINS is a valid and reliable practical tool to measure cognitive insight in OCRDs and might help toward clarifying the role of cognitive insight in this population.

What makes an obsession? A systematic-review and meta-analysis on the specific characteristics of intrusive cognitions in OCD in comparison with other clinical and non-clinical populations.

The Diagnostic and Statistical Manual 5th ed. defines obsessions in obsessive-compulsive disorder (OCD) as frequent, persistent, intrusive, unwanted thoughts that provoke anxiety and distress and lead to attempts to neutralize them with either thoughts or actions. However, no systematic review has yet evaluated characteristics that are specific to obsessions occurring in OCD. The aim of the current systematic review and meta-analysis was to investigate the specific features of obsessions occurring in OCD by comparing them to both obsessionally and non-obsessionally-themed intrusions in non-clinical and other clinical populations. Based on a registered protocol, 832 records were found, of which 15 were included in the systematic review and meta-analysis, with a total of 1891 participants. Obsessionally-themed intrusions that occur among those with OCD caused more distress, guilt, negative emotion and interference as compared to similarly-themed intrusions that occur within the general population. The distinction between obsessionally-themed intrusions among those with OCD as compared to those occurring in anxiety and depressive disorder primarily revolves around a higher level of persistence, pervasiveness and distress associated with their occurrence. Further, unacceptability, uncontrollability, ego-dystonicity, alienness, guilt, the form of the intrusion, association with the self and lack of any basis in reality also differentiates between obsessions and intrusions occurring in other disorders. Obsessions share many characteristics with thoughts occurring in other disorders and can be distinguished using a combination of characteristics specific to individual disorders.

COVID-19 related stress and fears of contamination: the impact of feared self-perceptions.

Specific concerns have been raised for those suffering from obsessive-compulsive disorder (OCD) during the COVID-19 pandemic, particularly those suffering from contamination fear. Investigation in non-clinical and OCD samples have reported an increase in contamination symptoms in association with the severity of the COVID-19 pandemic. In particular, stress related to COVID-19 has been found to be a major predictor of an increase in contamination symptoms. It has also been suggested that these effects may be accounted for by feared-self perceptions, that renders certain individuals more vulnerable to COVID-related stress and its effect on contamination-related symptomatology. We hypothesized that feared self-perceptions would predict COVID-19-related stress and that both feared self-perceptions and COVID-19-related stress would predict contamination symptoms while controlling for age, education and sex. To test this hypothesis, 1137 community participants completed online questionnaires. Path analysis confirmed our hypotheses highlighting the importance of feared self-perceptions during the COVID-19 pandemic in its effect on stress and ensuing symptomatology. Further, women scored higher on questionnaires, but the relationship between feared self-perceptions, COVID-19-related stress and contamination symptoms remained similar. Implications for theory and research are discussed.

Evaluation of Inference-Based Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder: A Multicenter Randomized Controlled Trial with Three Treatment Modalities.

INTRODUCTION: Inference-based cognitive-behavioral therapy (I-CBT) is a specialized psychological treatment for obsessive-compulsive disorder (OCD) without deliberate and prolonged exposure and response prevention (ERP) that focuses on strengthening reality-based reasoning and correcting the dysfunctional reasoning giving rise to erroneous obsessional doubts and ideas. OBJECTIVE: The present study aimed to evaluate the effectiveness of I-CBT through a comparison with appraisal-based cognitive behavioral therapy (A-CBT) and an adapted mindfulness-based stress reduction (MBSR) intervention. METHODS: This was a two-site, parallel-arm randomized controlled trial (RCT) comparing I-CBT with A-CBT. The MBSR intervention acted as a non-specific active control condition. Following formal evaluation, 111 participants diagnosed with OCD were randomly assigned. The principal outcome measure was the Yale-Brown Obsessive-Compulsive Scale. RESULTS: All treatments significantly reduced general OCD severity and specific symptom dimensions without a significant difference between treatments. I-CBT was associated with significant reductions in all symptom dimensions at post-test. Also, I-CBT led to significantly greater improvement in overvalued ideation, as well as significantly higher rates of remission as compared to MBSR at mid-test. CONCLUSIONS: I-CBT and MBSR appear to be effective, alternative treatment options for those with OCD that yield similar outcomes as A-CBT. I-CBT may have an edge in terms of the rapidity by which patients reach remission, its generalizability across symptom dimension, its potentially higher level of acceptability, and effectiveness for overvalued ideation. Future research is needed to assess whether additional alternative treatments options can help to increase the number of people successfully treated.

OCD is Not a Phobia: An Alternative Conceptualization of OCD.

While the Diagnostic and Statistical Manual Version 5 (DSM-5) has separated obsessive-compulsive disorder (OCD) from other anxiety disorders, conceptualization and treatment of OCD is still identical to the conceptualization and treatment of phobias. Many differences exist between phobias and OCD justifying a different conceptualization and treatment modality for OCD. Implications of the phobic model for OCD are discussed and its limitations are shown. Ethical and counterproductive forms of treatment for OCD derived from the phobic model are also presented. An alternative conceptualization of OCD, the inference-based approach, is presented to show that the phobic model is not the only one which can be applied to OCD. Advantages of this non-phobic way of conceptualizing OCD is illustrated and discussed.

Group cognitive-behavioural therapy for hoarding disorder: Systematic review and meta-analysis.

Previous meta-analysis has reported the rate of reliable and clinically significant changes in hoarding disorder (HD) after cognitive-behavioural therapy (CBT) based on the classical CBT model of HD, as between 42% and 25%. However, in this analysis, different types of therapy (group vs individual, G-CBT and I-CBT, respectively), different providers (psychologist vs nonpsychologist), and different diagnosis (HD vs hoarding behaviour) were analysed together. Hence, it remains unclear if reported rate of changes was due to limits of the CBT model of HD or due to the fact that different applications of the model were analysed together. The aim of this meta-analysis is to highlight shortcomings in the description of existing approaches in G-CBT in HD and provide an up-to-date review of the current state of efficacy. We searched references for treatment trials of G-CBT for HD in adults with object hoarding, where treatment was conducted by a professional in PubMed, PsychINFO and Web of Science databases, and ResearchGate (for grey literature). Data on participants, treatment modalities, and outcomes were extracted; treatment effect-size was meta-analysed. Five hundred and forty-three references were found; after title and abstract screening, eight articles (178 participants) were retained of which seven were included in the meta-analysis. G-CBT showed improvement of HD severity at posttreatment (Hedge's g = 0.96). The rate of clinically reliable changes across groups of treatment was 21%-68% (M = 36.7%; SD = 12.1%). The meta-analyses showed a statistically but not clinically significant impact of age on effect-size. No publication bias was found. There is strong evidence supporting the efficacy of G-CBT including modified or extended versions of classical G-CBT protocols. However, controlled trials with follow-up assessment are needed to evaluate long-term G-CBT efficacy for HD. As well, the rate of clinically significant changes is low; further research on the HD model could improve the efficacy of G-CBT.

Reduced fear-of-self is associated with improvement in concerns related to repugnant obsessions in obsessive-compulsive disorder.

OBJECTIVE: The potential causal and maintaining role of vulnerable self-themes and beliefs about the self in obsessive-compulsive disorder (OCD) have received increasing attention from cognitive-behavioural theorists. This interest was translated into the development of a self-report measurement of the feared self (the fear of who one might be or become), a construct theoretically and empirically pertinent to unwanted thoughts and impulses in OCD (i.e., repugnant obsessions). METHOD: The current study aimed to provide converging evidence on the relevance of the feared self in OCD, by examining whether improvements in symptoms associated with repugnant obsessions (measured on the Vancouver Obsessional Compulsive Inventory [VOCI] obsessions subscale) would be predicted by reduced feared self-perceptions (measured on the Fear-of-Self Questionnaire [FSQ]) in a sample of 93 patients receiving psychotherapy for OCD. RESULTS: Using a series of hierarchical linear regression models, we found that treatment-related reductions on the FSQ significantly and uniquely predicted reductions on the VOCI obsessions subscale and the contamination subscale. CONCLUSIONS: The current study thus replicated previous research suggesting the relevance of the feared possible self in psychological disorders such as OCD, where negative self-perception is a dominant theme. PRACTITIONER POINTS: Current results suggest that changes in feared self-perceptions may be the mechanism through which OCD symptoms improve via therapy. Interventions specifically aimed at changing feared self-perceptions may prove effective in improving cognitive-behavioural treatments for OCD. One limitation of the current study is the lack of behavioural measures of OCD to supplement self-report measures of OCD. Another limitation is that the small number of patients receiving some of the treatments precludes investigations into which treatments may be more effective in altering feared self-perceptions.

Group cognitive-behavioural treatment with long-term follow-up and targeting self-identity for hoarding disorder: An open trial.

BACKGROUND: Group cognitive-behavioural therapy (G-CBT) for hoarding disorder (HD) may be an intervention of choice, considering its efficacy, low costs, and impact on comorbid anxiety and depression. But although G-CBT and modifications of G-CBT have been applied, none has assessed G-CBT efficacy at follow-up. In the current open-label pilot study, we tested the efficacy of G-CBT at posttreatment and 6-month follow-up and whether the inclusion of targeted reasoning and self-identity components added to G-CBT efficacy. METHODS: Participants (n = 16) with the HD according to the DSM-5 criteria without major comorbid conditions and not requiring immediate medical intervention were retained. The intervention included a 20-week G-CBT with the inclusion of modules on reasoning and self-identity. RESULTS: Very large/large effect sizes, depending on the outcome measure, were observed at posttreatment. Also, HD severity decreased from posttreatment to 6-month follow-up. All participants showed reliable change from pretreatment to follow-up. CONCLUSIONS: The results emphasize the efficacy of G-CBT with additional targeted reasoning and self-components.

The role of feared possible selves in obsessive-compulsive and related disorders: A comparative analysis of a core cognitive self-construct in clinical samples.

Increasingly, cognitive-behavioural models have been considering the role of beliefs about the self in the development and maintenance of obsessive-compulsive disorder (OCD), including sensitive domains of self-concept and feared self-perceptions. This has led to the development of the Fear of Self Questionnaire (FSQ; Aardema et al., ), which has shown strong internal consistency, divergent and convergent validity, and found to be a major predictor of unwanted thoughts and impulses (i.e., repugnant obsessions). The current study aimed to investigate fear of self-perceptions using the FSQ in an OCD sample (n = 144) and related psychological disorders (eating disorders, n = 57; body dysmorphic disorder, n = 33) in comparison to a non-clinical (n = 141) and clinical comparison group (anxiety/depressive disorders, n = 27). Following an exploratory factor analysis of the scale in the OCD sample, the results showed that participants with OCD in general did not score significantly higher on fear of self-perceptions than did the clinical comparison participants. However, consistent with previous findings, fear of self was highly characteristic among OCD patients with unwanted repugnant thoughts and impulses. In addition, fear of self-perceptions were significantly more elevated in those with eating or body dysmorphic disorders relative to the other non-clinical and clinical groups. The construct of a "feared possible self" may be particularly relevant in disorders where negative self-perception is a dominant theme, either involving concerns about one's inner self or concerns related to perceived bodily faults.

Cognitive psychophysiological treatment of bodily-focused repetitive behaviors in adults: An open trial.

BACKGROUND: Body-focused repetitive behaviors (BFRBs), such as hair pulling, skin picking, and nail biting, are repetitive, destructive, and nonfunctional habits that cause significant distress. Separate BFRBs form a cohesive group and could be assessed as part of the Tourette/tic spectrum or obsessive-compulsive spectrum of disorders. The treatment of choice is either antidepressant or behavioral treatment, both of which have shown effectiveness. The cognitive psychophysiological (CoPs) model focuses on the tension and emotional build up that triggers habits by addressing cognitive-behavioral, emotional and psychophysiological processes preceding onset rather than the habit itself. The CoPs approach has already shown efficacy in treatment of tic and Tourette disorder. OBJECTIVE: The aim of the current open trial was to view whether BFRBs can be validly assessed on a standard tic scale (Tourette Symptom Global Scale; TSGS) and evaluate the efficacy of the CoPs intervention on 64 participants (54 completers) with 1 of 3 subtypes of BFRBs (hair pulling, nail biting, and skin picking) compared to a waitlist control. METHOD: Participants were assessed at baseline on an adapted TSGS and after receving 14 weeks of CoPs therapy with six months follow up. RESULTS: The TSGS was reliably and validly adapted to measure BFRBs. The CoPs intervention was effective for all BRFB subtypes with a large effect size (intention-to-treat g = 1.54; completers g = 2.04), with 74% of patients showing clinically significant improvement. Mood and self-esteem also improved posttreatment. The decrease in symptoms was maintained at the 6-month follow-up, with a further decrease in perfectionism. CONCLUSION: BFRBs can be reliably assessed as a tic spectrum disorder rather than as part of the obsessive-compulsive spectrum. The CoPs model may offer a complementary treatment for BFRBs.

Inductive reasoning and doubt in obsessive compulsive disorder.

BACKGROUND AND OBJECTIVES: Previous studies show that individuals with obsessive compulsive disorder (OCD) accord more importance than healthy controls (HC) to alternative conclusions, resulting in increased doubt regarding an initial conclusion. The goal of the present study was to replicate and extend this finding. METHODS: Eighteen participants diagnosed with OCD and 16 HC completed the Reasoning with Inductive Arguments Task (RIAT), which operationalizes doubt as change in confidence towards a conclusion after alternative conclusions are presented. To examine conditions that facilitate doubt, the impact of alternative conclusions that both supported and contradicted the initial conclusion was compared, as well as the effect of neutral and OCD-relevant item content. RESULTS: Both the OCD and HC groups decreased confidence after contradicting conclusions, but only the HC group increased confidence when presented with supporting conclusions. Furthermore, decrease in confidence in the OCD group correlated with OCD symptom severity. LIMITS: The RIAT could be adapted to better take into account of OCD subtypes. CONCLUSION: Doubt generation may contribute to obsessional doubting.

Augmentation of Psychotherapy through Alternative Preconscious Priming: A Case Series Exploring Effects on Residual Symptoms.

The current paper describes a case series using a new strategy for facilitating change based on Augmentation of Psychotherapy through Alternative Preconscious Priming (APAP) (1) in the treatment of eight treatment-resistant patients suffering from social phobia or generalized anxiety disorder. The patients had previously only shown a partial response to cognitive behavioral therapy (CBT) despite good treatment adherence. The patients completed APAP using a computerized program, which consisted of three steps during which alternative, more functional thoughts and beliefs relevant to the idiosyncratic difficulties experienced by the patients were formulated. Subsequently, these formulations were recorded and mixed with masking relaxing music, which the patient listened to in a passive state twice daily for 20 min for a period of 8 weeks. This case series aimed to assess the effect and acceptability of APAP using quantitative and qualitative measures administered before, after, and 16 weeks' posttreatment. Results showed a reduction in dysfunctional idiosyncratic thoughts reported by most patients, as well as mild improvements in anxiety and important improvements in quality of life. APAP could be a valuable addition to CBT by facilitating or enhancing cognitive and symptom change. Further studies are needed to confirm these promising results.

Over facilitation of unadapted cognitive processes in obsessive compulsive disorder as assessed with the computerized mirror pointing task.

Response inhibition has been suggested to be dysfunctional in obsessive-compulsive disorder (OCD). However, this process involves intentional cognitive control, which does not correspond to the automatic emergence of stereotyped thoughts and behaviours usually reported by patients with OCD. In the present study, the excessive facilitation of unintentional processes was assessed in OCD by using the Computerized Mirror Pointing Task (CMPT). Seventy-six volunteers participated in this study, including 39 patients with OCD and 37 healthy controls. The CMPT was administered to all participants, and a score of appropriateness of the sensorimotor adaptation to the mirror inversion was computed from the initial deviation angle (IDA), that precedes the intentional readjustment of movement. Results showed that throughout the 40 trials of the CMPT, the IDA score remained significantly abnormal in patients with OCD in comparison with control participants. Further analyses of IDA scores in OCD revealed a clear tendency to keep a natural visuomotor processing that is rigid and unadapted to the mirror condition. Irrespective of the physical requirements of the environment, patients with OCD showed a strong tendency to initiate movements as per a previously consolidated - although unadapted - sensorimotor mapping. This suggests a tendency for an excessive facilitation of unintentional stereotyped processes. Further studies should be conducted on this question by using tasks sensitive to cognitive processes other than visuo-spatial abilities.

The Inference-Based Approach (IBA) to the Treatment of Obsessive-Compulsive Disorder: An Open Trial Across Symptom Subtypes and Treatment-Resistant Cases.

The current open trial evaluated an inference-based approach (IBA) to the treatment of obsessive-compulsive disorder (OCD) across symptom subtypes and treatment-resistant cases. Following formal diagnosis through semi-structured interview by an independent evaluator, a total of 125 OCD participants across five major symptom subtypes entered a program of 24 sessions of treatment based on the IBA. An additional group of 22 participants acted as a natural wait-list control group. Participants were administered the Yale-Brown Obsessive-Compulsive Scale before and after treatment as the principal outcome measure, as well as measures of negative mood states, inferential confusion and obsessive beliefs. Level of overvalued ideation was assessed clinically at pre-treatment using the Overvalued Ideation Scale. After 24 weeks of treatment, 102 treatment completers across all major subtypes of OCD showed significant reductions on the Yale-Brown Obsessive-Compulsive Scale with effect sizes ranging from 1.49 to 2.53 with a clinically significant improvement in 59.8% of participants. No improvement was observed in a natural wait-list comparison group. In addition, IBA was effective for those with high levels of overvalued ideation. Change in inferential confusion and beliefs about threat and responsibility were uniquely associated with treatment outcome. The study is the first large-scale open trial showing IBA to be effective across symptom subtypes and treatment-resistant cases. The treatment may be particularly valuable for those who have previously shown an attenuated response to other treatments. Copyright © 2016 John Wiley & Sons, Ltd. KEY PRACTITIONER MESSAGE: Psychological treatment based on the inference-based approach is an effective treatment for all major subtypes of obsessive-compulsive disorder. The treatment is equally effective for those with high and low levels of overvalued ideation. Treatment based on the inference-based approach may be particularly valuable for those who have shown an attenuated response to cognitive-behaviour therapy as usual.