Co-occurring PTSD in intensive OCD treatment: Impact on treatment trajectory vs. response.

BACKGROUND: Obsessive-compulsive disorder (OCD) and co-occurring posttraumatic stress disorder (PTSD) is associated with more severe and chronic OCD. However, findings regarding treatment effectiveness of cognitive behavioral treatment (CBT) with exposure and response prevention (ERP) with this comorbidity are mixed. Research aimed at understanding the precise barriers to OCD treatment effectiveness for individuals with co-occurring PTSD may help elucidate unique treatment needs. METHODS: The current study used linear regression and latent growth curve analysis comparing treatment response and trajectory from patients with OCD (n = 3083, 94.2 %) and OCD + PTSD (n = 191, 5.2 %) who received CBT with ERP in two major intensive OCD treatment programs. RESULTS: Although patients with OCD + PTSD evidenced similar trajectories of overall severity change, patients at one site required nearly 11 additional treatment days to achieve comparable reduction in OCD severity. Further, at the dimensional level, those with OCD + PTSD had poorer treatment response for unacceptable thoughts and symmetry symptoms. The moderate effect for unacceptable thoughts, indicating the widest gap in treatment response, suggests these symptoms may be particularly relevant to PTSD. LIMITATIONS: Findings are limited by a naturalistic treatment sample with variation in treatment provision. CONCLUSIONS: Findings emphasize caution in using a one-size-fits-all approach for patients with co-occurring OCD + PTSD within intensive OCD treatment programs, as broadly defined outcomes (e.g., reduction in overall severity) may not translate to reduction in the nuanced symptom dimensions likely to intersect with trauma. Unacceptable thoughts and symmetry symptoms, when co-occurring with PTSD, may require a trauma-focused treatment approach within intensive OCD treatment.

Common rituals in obsessive-compulsive disorder and implications for treatment: A mixed-methods study.

Obsessive-compulsive disorder (OCD) is characterized by engagement in rituals that serve to obtain certainty and prevent feared outcomes. Exposure and response prevention is most effective when rituals are resisted, yet existing self-report measures of OCD limit identification of the full range of possible rituals, and little is known about how rituals might cluster together and predict worsened severity and poorer treatment outcomes. In a retrospective sample of 641 adult patients who received intensive OCD treatment, the present study used a mixed-methods approach to (a) identify and validate treatment provider-identified rituals using the Yale-Brown Obsessive-Compulsive Scale, (b) identify clustering patterns of rituals, and (c) examine the impact of these clusters on severity and treatment outcomes. Sixty-two discrete rituals clustered into eight higher order ritual clusters: avoidance, reassurance, checking, cleaning/handwashing, just right, rumination, self-assurance, and all other rituals. At admission, reassurance predicted greater intolerance of uncertainty (IU) and rumination predicted less OCD severity. Only one ritual cluster-just right-predicted treatment outcomes; patients with just right rituals had worse IU at discharge and significantly longer length of treatment (average 7.0 days longer). Clinical observation can identify more nuanced and individualized rituals than self-report assessment alone. Patients presenting with just right rituals may benefit less from treatment focused on harm avoidance and habituation; instead, treatment should be tailored to the idiosyncrasies of incompleteness and not just the right experiences. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Using the Child Sheehan Disability Scale to Differentiate Severity Level in Youth With Anxiety Disorders and Obsessive Compulsive Disorder.

The current study extends the psychometric support for the Child Sheehan Disability Scale (CSDS) as a measure of impairment associated with childhood anxiety disorders, including obsessive compulsive disorder. The CSDS was completed by 1,481 predominately Caucasian youth (55.4% female) ages 8 to 17 (M = 12.68, SD = 2.78) from primarily two-parent households and a parent across community, outpatient, intensive outpatient treatment, and residential settings. The results replicated and extended the previously found strong convergent validity, discriminant validity, and treatment sensitivity with a revised parent-report item in the larger sample. Moreover, the CSDS successfully differentiated between patients receiving treatment of different levels of intensity. These data were used to develop preliminary qualitative descriptors associating individual scores with a likely level of indicated treatment to enhance the clinical applicability of the CSDS. This study establishes the CSDS as one of the briefest and most rigorously evaluated measures of impairment associated with child anxiety. However, the performance of the CSDS must be examined in more representative samples before being applied to diverse populations.

Co-occurring depression and obsessive-compulsive disorder: A dimensional network approach.

BACKGROUND: Depressive and obsessive-compulsive (OCD) symptoms often co-occur and a number of possible explanations for this co-occurrence have been explored, including shared biological and psychosocial risk factors. Network approaches have offered a novel hypothesis for the link between depression and OCD: functional inter-relationships across the symptoms of these conditions. The few network studies in this area have relied largely on item, rather than process-level constructs, and have not examined relationships dimensionally. METHODS: Network analytic methods were applied to data from 463 treatment-seeking adults with OCD. Patients completed self-report measures of OCD and depression. Factor analysis was used to derive processes (i.e., nodes) to include in the network. Networks were computed, and centrality, bridge, and stability statistics examined. RESULTS: Networks showed positive relations among specific OCD and depressive symptoms. Obsessions (particularly repugnant thoughts), negative affectivity, and cognitive-somatic changes (e.g., difficulty concentrating) were central to the network. Unique relations were observed between symmetry OCD symptoms and cognitive-somatic changes. No direct link between harm-related OCD symptoms and depression was observed. CONCLUSIONS: Our results bring together prior findings, suggesting that both negative affective and psychomotor changes are important to consider in examining the relationship between OCD and depression. Increased consideration of heterogeneity in the content of OCD symptoms is key to improving clinical conceptualizations, particularly when considering the co-occurrence of OCD with other disorders.

Symptom severity and presentation in comorbid OCD and PTSD: A clinical replication.

Individuals with comorbid obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD) experience more severe OCD symptoms and poorer treatment response. Despite some evidence linking OCD symptom domains to trauma, only one study to date has examined typical OCD and PTSD presentations in individuals with OCD+PTSD, and findings were based on a nonclinical sample. The current study sought to replicate findings in a clinical sample of 1,014 patients diagnosed with OCD (n = 928), PTSD (n = 40), and OCD+PTSD (n = 46) in specialty OCD and anxiety treatment programs. Consistent with previous research, patients with OCD+PTSD reported more severe OCD yet similar severity PTSD symptoms and did not evidence a unique phenotypic presentation once symptom overlap and comorbid mood and personality disorders were considered. OCD+PTSD is equally as heterogeneous as OCD and PTSD alone. Implications for the research and treatment of OCD+PTSD are discussed, and assessment and treatment recommendations are provided.

Transgender and Gender Diverse Patients in Intensive Mood Disorder Treatment: A Comparative Examination of Clinical Presentation and Treatment Outcomes.

Individuals who are transgender and gender diverse (TGD) are more likely to suffer from and to seek mental health services for mood disorders. Some literature suggests that TGD individuals, because of pervasive and systemic minority stress, may have more complex clinical presentations (i.e., psychiatric conditions and severity of symptoms) and may benefit from empirically based treatments to a lesser degree than their cisgender peers. However, research has yet to examine individuals who are TGD receiving treatment in specialized, intensive mood disorder treatment despite the propensity for them to be diagnosed with and treated for mood disorders. Using a sample of 1,326 adult patients in intensive mood disorder treatment (3.8% TGD), the clinical presentation and treatment outcomes were compared between patients who are TGD and cisgender. Contrary to previous research, TGD patients were largely similar if not healthier than their cisgender counterparts, including similar depression severity, quality of life, emotion dysregulation, and behavioral activation, and less severe rumination at admission. Despite similar to better reported mental health symptoms, TGD patients were diagnosed with more psychiatric conditions overall, including greater prevalence of social anxiety and neurodevelopmental diagnoses. Those who are TGD did not experience attenuated treatment response as predicted. Findings suggest that patients in intensive mood disorder treatment who are TGD may be more resilient than previously assumed, or supports may have increased to buffer effects of stigma on mental health, and emphasize the need to exercise discretion and sensitivity in diagnostic practices to prevent over-diagnosis and pathologizing of TGD individuals.

Co-Occurring Obsessive-Compulsive and Posttraumatic Stress Disorder: A Review of Conceptualization, Assessment, and Cognitive Behavioral Treatment.

Posttraumatic stress disorder (PTSD) co-occurs with obsessive-compulsive disorder (OCD) nearly 25% of the time, and rates of co-occurring OCD within PTSD populations are even higher. Several studies examining the impact of co-occurring OCD and PTSD with suggest attenuated treatment response, yet findings regarding symptom presentation in this population are mixed. Given phenotypic, functional, and sometimes etiological overlap in OCD and PTSD, differential diagnosis and specialized treatment can be a complex yet important undertaking. This paper reviews the current literature on co-occurring OCD and PTSD; describes the theoretical conceptualization for the intersection of OCD and PTSD; offers recommendations for differential assessment and cognitive behavioral treatment; and provides directions for future research on co-occurring OCD and PTSD.

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.

Clinical Presentation and Treatment Trajectory of Gender Minority Patients With Obsessive-Compulsive Disorder.

Gender minorities experience unique minority stressors that increase risk for psychiatric disorders. Notably, gender minorities are four and six times more likely than their cisgender female and male peers, respectively, to be treated for or diagnosed with obsessive-compulsive disorder (OCD). Despite higher rates of OCD, more psychiatric comorbidities, and minority stressors, little is known about the clinical presentation and treatment outcomes of gender minorities with OCD. Using a sample of 974 patients in specialty treatment programs for OCD, the current study found that gender minorities reported more severe contamination symptoms and greater incidence of comorbid substance use/addiction, trauma/stressor-related, personality, and other/miscellaneous disorders compared to cisgender male and female patients. Despite significantly longer lengths of stay, gender minorities reported less symptom improvement across treatment compared to cisgender male and female patients. Findings underscore the need for continued research to improve the effectiveness and individualization of treatment for gender minorities with OCD.

OCD in the time of COVID-19: A global pandemic's impact on mental health patients and their treatment providers.

Individuals with obsessive-compulsive disorder (OCD) have evidenced resilience against large-scale crises, although emerging research on the impact of COVID-19 is mixed. Little is known about the impact of COVID-19 on mental health providers. Items from an instrument evaluating the impact of the September 11, 2001, terrorist attack were adapted to measure the impact of COVID-19 on emotions, cognitions, and behaviors. Using a sample of 65 patients with primary OCD diagnoses and OCD treatment providers in intensive programs for OCD and anxiety, the authors found that COVID-19 evidenced a less significant overall impact on patients than providers. Specifically, providers reported more significant impact on the amount of time spent worrying about COVID-19, taking additional cleaning and sanitization precautions, and time spent socializing with loved ones. Findings support previous literature indicating that individuals with OCD demonstrate resilience to large-scale crises, and offer insights into the specific struggles of providers who treat OCD.

Does a unique co-occurring OCD and PTSD factor structure exist?: Examination of overlapping OCD and PTSD symptom clusters.

OCD and PTSD share many commonalities, including phenotypic and functional overlap in symptoms. Specifically, both disorders are characterized by unwanted, intrusive, anxiety/distress-eliciting intrusive thoughts and evoking behaviors intended to control, neutralize, suppress, or outright avoid intrusive thoughts and associated anxiety/distress. Extant factor analytic research supports a model of PTSD at odds with current DSM-5 criteria, and no examination of the factor structure of comorbid OCD+PTSD currently exists despite the noted overlap in symptomatology and high rates of comorbidity. Using a sample of 4073 patients diagnosed with OCD and/or PTSD enrolled in intensive treatment programs for OCD or PTSD, multigroup confirmatory factor analysis (MGCFA) and measurement invariance tests were run to determine the best fitting model of OCD and PTSD symptoms in patients with OCD+PTSD. Four models were compared across patients with OCD, PTSD, and OCD+PTSD: DSM-5 and 7-factor hybrid PTSD models with OCD symptoms structured as either combined or comorbid constructs. The comorbid hybrid model proved the best fit, and both hybrid models evidenced better fit than DSM-5 models. The current study lends additional support for the hybrid model of PTSD and suggests that there is no existence of a unique factor structure of OCD and PTSD symptoms in individuals with the comorbid conditions.

Efficacy of intensive CBT telehealth for obsessive-compulsive disorder during the COVID-19 pandemic.

Despite evidence for the effectiveness of cognitive behavioral therapy (CBT) for obsessive-compulsive disorder (OCD), many individuals with OCD lack access to needed behavioral health treatment. Although some literature suggests that virtual modes of treatment for OCD are effective, it remains unclear whether intensive programs like partial hospitalization and intensive outpatient programs (PHP and IOPs) can be delivered effectively over telehealth (TH) and within the context of a global pandemic. Limited extant research suggests that clinicians perceive attenuated treatment response during the pandemic. The trajectory and outcomes of two matched samples were compared using linear mixed modeling: a pre-COVID in-person (IP) sample (n = 239) and COVID TH sample (n = 239). Findings suggested that both modalities are effective at treating OCD and depressive symptoms, although the pandemic TH group required an additional 2.6 treatment days. The current study provides evidence that PHP and IOP treatment delivered via TH during the COVID-19 pandemic is approximately as effective as pre-pandemic IP treatment and provides promising findings for the future that individuals with complicated OCD who do not have access to IP treatment can still experience significant improvement in symptoms through TH PHP and IOP treatment during and potentially after the pandemic.

Comparing efficacy of telehealth to in-person mental health care in intensive-treatment-seeking adults.

The heightened acuity in anxiety and depressive symptoms catalyzed by the COVID-19 pandemic presents an urgent need for effective, feasible alternatives to in-person mental health treatment. While tele-mental healthcare has been investigated for practicability and accessibility, its efficacy as a successful mode for delivering high-quality, high-intensity treatment remains unclear. This study compares the clinical outcomes of a matched sample of patients in a private, nation-wide behavioral health treatment system who received in-person, intensive psychological treatment prior to the COVID-19 pandemic (N = 1,192) to the outcomes of a distinctive group of patients who received telehealth treatment during the pandemic (N = 1,192). Outcomes are measured with respect to depressive symptoms (Quick Inventory of Depressive Symptomatology-Self-Report; QIDS-SR) and quality of life (Quality of Life Enjoyment and Satisfaction Questionnaire; Q-LES-Q). There were no significant differences in admission score on either assessment comparing in-person and telehealth groups. Patients in the partial hospitalization level of care stayed longer when treatment was remote. Results suggest telehealth as a viable care alternative with no significant differences between in-person and telehealth groups in depressive symptom reduction, and significant increases in self-reported quality of life across both groups. Future research is needed to replicate these findings in other healthcare organizations in other geographical locations and diverse patient populations.

Knowledge and competency standards for specialized cognitive behavior therapy for adult obsessive-compulsive disorder.

Obsessive-Compulsive Disorder (OCD) is a leading cause of disability world-wide (World Health Organization, 2008). Treatment of OCD is a specialized field whose aim is recovery from illness for as many patients as possible. The evidence-based psychotherapeutic treatment for OCD is specialized cognitive behavior therapy (CBT, NICE, 2005, Koran and Simpson, 2013). However, these treatments are not accessible to many sufferers around the world. Currently available guidelines for care are deemed to be essential but insufficient because of highly variable clinician knowledge and competencies specific to OCD. The phase two mandate of the 14 nation International OCD Accreditation Task Force (ATF) created by the Canadian Institute for Obsessive Compulsive Disorders is development of knowledge and competency standards for specialized treatments for OCD through the lifespan deemed by experts to be foundational to transformative change in this field. This paper presents knowledge and competency standards for specialized CBT for adult OCD developed to inform, advance, and offer a model for clinical practice and training for OCD. During upcoming ATF phases three and four criteria and processes for training in specialized treatments for OCD through the lifespan for certification (individuals) and accreditation (sites) will be developed based on the ATF standards.

Intolerance of uncertainty and obsessive-compulsive disorder dimensions.

Intolerance of uncertainty (IU), which can include prospective (i.e., desire for predictability) and inhibitory (i.e., uncertainty paralysis) IU, is widely understood to be a central underlying component of obsessive-compulsive disorder (OCD). IU has several treatment implications, yet research on the differences in IU underlying OCD dimensions is limited and does not account for covarying effects of overlapping symptoms, shared variance in IU, demographic variables, and comorbid psychiatric conditions like generalized anxiety disorder (GAD) and posttraumatic stress disorder (PTSD). A sample of 974 patients with diagnosed OCD enrolled in residential, partial hospitalization, and intensive outpatient treatment programs for OCD and anxiety completed self-report measures of OCD symptoms and IU at admission. Structural equation modeling included prospective. inhibitory IU, and common IU and covariates (i.e., race, ethnicity, level of care, and comorbid GAD and PTSD) as predictors of four common OCD dimensions found that contamination and unacceptable thoughts symptoms evidenced a unique relationship with IU. Specifically, whereas a common IU factor predicted all four OCD symptom dimensions, inhibitory IU uniquely predicted contamination and unacceptable thoughts symptoms over and above covarying effects. Individuals with contamination and unacceptable thoughts symptoms may be more likely to feel "paralyzed" by uncertainty due to overreliance on overt immediate rituals, outright avoidance, rumination, or difficulties with emotion regulation, and may benefit from additional psychoeducation, problem-solving, and accountability. Broadly, individuals with OCD may benefit from explicit discussions about IU-related expectancies and disconfirmation of fears.

The effects of depression on the treatment of OCD in a residential sample.

Studies investigating the impact of depressive symptoms on obsessive-compulsive disorder (OCD) treatment have yielded mixed findings. The purpose of the study is to extend previous research, which primarily used outpatient samples, to determine whether depression affects OCD treatment outcome among patients receiving intensive residential treatment. OCD patients receiving residential treatment based primarily on exposure and response prevention (ERP) provided data regarding symptoms of depression and OCD at admission and discharge. Patients reported large and significant reductions in OCD symptoms over the course of treatment. Change in OCD symptoms was not significantly affected by depressive symptoms, including patients with severe depressive symptoms. Change in depressive symptoms over the course of treatment was, however, robustly related to change in OCD symptoms, especially among patients who began treatment with severe symptoms of depression. These findings suggest that cognitive-behavior therapy delivered in a residential treatment setting drastically reduces OCD symptoms regardless of depressive symptoms.

Little Doubt That CBT Works for Pediatric OCD.

We write with great concern in response to the recent systematic review and meta-analysis of cognitive-behavioral therapy (CBT) in pediatric obsessive-compulsive disorder (OCD) by Uhre et al.1 Although the authors' results consistently support the clinical efficacy of CBT for pediatric OCD, we expect that, much like ourselves, readers will be confused by the discordant and inappropriate conclusions that they put forward. These conclusions stem from the authors' application and interpretation of their particular qualitative methods, which could lead important stakeholders (eg, parents, patients, clinicians, and payers) to wrongly discount clear evidence for what is known to be the best evidence-based therapy for pediatric OCD.

Predictors of treatment outcome for youth receiving intensive residential treatment for obsessive-compulsive disorder (OCD).

Little is known about the predictors of outcome from intensive residential treatment of OCD. This study aimed to examine age, gender, and baseline OCD severity, as well as measures of comorbid anxiety and depressive, internalizing/externalizing, and inattention symptoms, as predictors of treatment outcome in adolescents receiving intensive residential treatment for OCD. The sample comprised 314 adolescents aged 13-17 years with treatment-resistant OCD and a Children's Yale-Brown Obsessive-Compulsive Scale Self-Report (CY-BOCS-SR) total score ≥16. Bivariate and multiple regression models were used to evaluate the predictors of continuous OCD severity outcome and treatment response. Results of the bivariate regression analyses of predictors demonstrated that length of treatment, pre-treatment OCD severity, and symptoms of anxiety and depression significantly predicted post-treatment OCD severity, while only symptoms of depression and anxiety predicted treatment response. When including all predictors in the same model, only baseline OCD severity remained a significant predictor of post-treatment OCD severity, and none of the assessed variables significantly predicted treatment response. Results indicate that low pre-treatment OCD severity predicts lower OCD severity following treatment, although it did not predict treatment response.

Cost-Effectiveness of Treatment Alternatives for Treatment-Refractory Pediatric Obsessive-Compulsive Disorder.

PURPOSE: Current guidelines for first-line treatment of childhood OCD are cognitive-behavioral therapy (CBT) utilizing exposure and response prevention (ERP), and/or antidepressant (ADM) pharmacotherapy, specifically serotonin reuptake inhibitors (SRI). Given that first-line are relatively similar in terms of clinical effectiveness, the role of costs to provide such services may help influence treatment decisions. In the case of treatment refractory pediatric OCD, this cost-effectiveness analysis (CEA) aims to further evaluate two additional, higher intensity combination therapies, namely OCD-specific Intensive Outpatient (IOP) and Partial Hospitalization Programs (PHP), to determine the additional benefits, in terms of effectiveness, that may result, and the corresponding increase in costs for these higher-intensity courses of therapy. RESULTS: IOP was the most cost-effective strategy in terms of change in CY-BOCS, pre/post treatment, equal to 16.42 units, followed by PHP and CBT monotherapy augmented with ADM CBT-monotherapy augmented with additional CBT and ADM-only augmented with CBT followed closely with 15.56 and 14.75 unit improvements in CY-BOCS. IOP accomplished its superior cost-effectiveness with an Incremental Cost-Effectiveness Ratio (ICER), of $48,834, lower than either of the established willingness to Pay thresholds. CONCLUSIONS: Lack of access to high fidelity, high dose CBT paired with pharmacotherapy is an issue for OCD patients and families. Among youth who were treatment non-responsive, these results indicate the superiority of a high dosage CBT strategy, indicating the need to increase access to these treatments.

Obsessive-compulsive symptoms in eating disorders: A network investigation.

OBJECTIVE: Eating disorders (EDs) are complex, heterogeneous, and severe psychiatric syndromes. They are highly comorbid with obsessive-compulsive disorder (OCD) which exacerbates the course of illness and impedes treatment. However, the direct functional relations between EDs and OCD symptoms remain largely unexplored. Hence, using network analysis, we investigated the relationship between ED and OCD at the level of symptoms in a heterogeneous clinical sample. METHOD: We used cross sectional data of 303 treatment-seeking patients with clinically relevant ED and OCD pathology. We constructed a regularized partial correlation network that featured both ED and OCD symptoms as nodes. To determine each symptom's influence, we calculated expected influence (EI) as an index of symptom centrality (i.e., "importance"). Bridge symptoms (i.e., symptoms from one syndromic cluster that have strong connections to symptoms of another syndromic cluster) were identified by computing bridge expected influence metrics. RESULTS: Fear of weight gain and dietary restraint were especially important among the ED symptoms. Interference due to obsessions was the key feature of OCD. ED and OCD clustered distinctly with few potential bridges between clusters. DISCUSSION: This study underscores the importance of cognitive symptoms for both ED and OCD although direct functional links between the two clusters are missing. Potentially, a network incorporating nodes capturing features of personality may account for diagnostic comorbidity better than specific symptoms of EDs or features of OCD do.