Improving Exposure Therapy: Rationale and Design of an International Consortium.

The Exposure Therapy Consortium (ETC) was established to advance the science and practice of exposure therapy. To encourage participation from researchers and clinicians, this article describes the organizational structure and activities of the ETC. Initial research working group experiences and a proof-of-principle study underscore the potential of team science and larger-scale collaborative research in this area. Clinical working groups have begun to identify opportunities to enhance access to helpful resources for implementing exposure therapy effectively. This article discusses directions for expanding the consortium's activities and its impact on a global scale.

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.

Latin American Trans-ancestry INitiative for OCD genomics (LATINO): Study protocol.

Obsessive-compulsive disorder (OCD) is a debilitating psychiatric disorder. Worldwide, its prevalence is ~2% and its etiology is mostly unknown. Identifying biological factors contributing to OCD will elucidate underlying mechanisms and might contribute to improved treatment outcomes. Genomic studies of OCD are beginning to reveal long-sought risk loci, but >95% of the cases currently in analysis are of homogenous European ancestry. If not addressed, this Eurocentric bias will result in OCD genomic findings being more accurate for individuals of European ancestry than other ancestries, thereby contributing to health disparities in potential future applications of genomics. In this study protocol paper, we describe the Latin American Trans-ancestry INitiative for OCD genomics (LATINO, https://www.latinostudy.org). LATINO is a new network of investigators from across Latin America, the United States, and Canada who have begun to collect DNA and clinical data from 5000 richly phenotyped OCD cases of Latin American ancestry in a culturally sensitive and ethical manner. In this project, we will utilize trans-ancestry genomic analyses to accelerate the identification of OCD risk loci, fine-map putative causal variants, and improve the performance of polygenic risk scores in diverse populations. We will also capitalize on rich clinical data to examine the genetics of treatment response, biologically plausible OCD subtypes, and symptom dimensions. Additionally, LATINO will help elucidate the diversity of the clinical presentations of OCD across cultures through various trainings developed and offered in collaboration with Latin American investigators. We believe this study will advance the important goal of global mental health discovery and equity.

On the importance of identifying mechanisms and active ingredients of psychological treatments.

This commentary addresses the thought-provoking article by Lorenzo-Luaces (in press). We review areas of both agreement and disagreement with the author's points, noting that readers should not infer that research into active ingredients and mechanisms is pointless. We conclude with a call for more research into the mechanisms of therapeutic change and the active ingredients of therapeutic interventions, with the aim of disseminating treatments that are both effective and efficient.

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

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

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).

Latin American Trans-ancestry INitiative for OCD genomics (LATINO): Study Protocol.

Obsessive-compulsive disorder (OCD) is a debilitating psychiatric disorder. Worldwide, its prevalence is ~2% and its etiology is mostly unknown. Identifying biological factors contributing to OCD will elucidate underlying mechanisms and might contribute to improved treatment outcomes. Genomic studies of OCD are beginning to reveal long-sought risk loci, but >95% of the cases currently in analysis are of homogenous European ancestry. If not addressed, this Eurocentric bias will result in OCD genomic findings being more accurate for individuals of European ancestry than other ancestries, thereby contributing to health disparities in potential future applications of genomics. In this study protocol paper, we describe the Latin American Trans-ancestry INitiative for OCD genomics (LATINO, www.latinostudy.org). LATINO is a new network of investigators from across Latin America, the United States, and Canada who have begun to collect DNA and clinical data from 5,000 richly-phenotyped OCD cases of Latin American ancestry in a culturally sensitive and ethical manner. In this project, we will utilize trans-ancestry genomic analyses to accelerate the identification of OCD risk loci, fine-map putative causal variants, and improve the performance of polygenic risk scores in diverse populations. We will also capitalize on rich clinical data to examine the genetics of treatment response, biologically plausible OCD subtypes, and symptom dimensions. Additionally, LATINO will help elucidate the diversity of the clinical presentations of OCD across cultures through various trainings developed and offered in collaboration with Latin American investigators. We believe this study will advance the important goal of global mental health discovery and equity.

The contribution of guilt sensitivity in the prediction of obsessive-compulsive disorder symptom dimensions: Replication and extension.

BACKGROUND: Obsessive-compulsive disorder (OCD) is associated with particular cognitive processes, such as beliefs about the importance of intrusive thoughts. The present study examined the explanatory power of guilt sensitivity to OCD symptom dimensions after controlling for well-established cognitive predictors. METHODS: 164 patients with OCD completed self-reported measures of OCD and depressive symptoms, obsessive beliefs, and guilt sensitivity. Bivariate correlations were examined, and latent profile analysis (LPA) was used to generate groups based on symptom severity scores. Differences in guilt sensitivity were examined across latent profiles. RESULTS: Guilt sensitivity was most strongly associated with unacceptable thoughts and responsibility for harm OCD symptoms, and moderately with symmetry. After controlling for depression and obsessive beliefs, guilt sensitivity added explanatory power to the prediction of unacceptable thoughts. LPA identified 3 profiles; profile-based subgroups significantly differed from one another in terms of guilt sensitivity, depression, and obsessive beliefs. CONCLUSIONS: Guilt sensitivity is relevant to various OCD symptom dimensions. Above and beyond depression and obsessive beliefs, guilt sensitivity contributed to the explanation of repugnant obsessions. Theory, research, and treatment implications are discussed.

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.

OCD and Comorbid Depression: Assessment, Conceptualization, and Cognitive Behavioral Treatment.

Many individuals with obsessive-compulsive disorder (OCD) also meet criteria for additional diagnoses. Among the most common co-occurring diagnoses are mood disorders-especially depression. This article focuses on the comorbidity between OCD and major depression. After discussing nature of OCD and depression, the rates and clinical impact of depression on OCD, the conceptualization, assessment, and treatment of OCD when it appears along with depression is covered in detail. The derivation and implementation of a cognitive behavioral treatment program specifically for depressed OCD patients is described and illustrated using a case example.

An ultra-brief screening scale for pediatric obsessive-compulsive disorder: The OCI-CV-5.

BACKGROUND: Obsessive-compulsive disorder (OCD) is an often disabling and chronic condition that is normally assessed using diagnostic interviews or lengthy self-report questionnaires. This makes routine screening in general health settings impractical, and as a result OCD is often under-(or mis-)recognized. The present study reports on the development of an ultra-brief version of the Obsessive-Compulsive Inventory-Child Version (OCI-CV) which may be administered routinely as a screener for pediatric OCD. METHOD: A total of 489 youth diagnosed with OCD, 259 non-clinical controls, and 299 youth with other disorders completed the OCI-CV and other indices of psychopathology. Using item analyses, we extracted five items and examined the measure's factor structure, sensitivity and specificity, and convergent and discriminant validity. RESULTS: We extracted five items that assess different dimensions of OCD (washing, checking, ordering, obsessing, neutralizing/counting), termed the OCI-CV-5. Results revealed that the measure possesses good to excellent psychometric properties, and a cutoff off (≥2) yielded optimal sensitivity and specificity. LIMITATIONS: Participants were predominantly White. In addition, more research is needed to examine the OCI-CV-5's test-retest reliability and sensitivity to treatment. CONCLUSIONS: The OCI-CV-5 shows promise as an ultra-brief self-report screener for identifying OCD in youth when in-depth assessment is unfeasible.

OCD and Comorbid Depression: Assessment, Conceptualization, and Cognitive-Behavioral Treatment.

Many individuals with obsessive-compulsive disorder (OCD) also meet criteria for additional diagnoses. Among the most common co-occurring diagnoses are mood disorders-especially depression. This article focuses on the comorbidity between OCD and major depression. After discussing nature of OCD and depression, the rates and clinical impact of depression on OCD, the conceptualization, assessment, and treatment of OCD when it appears along with depression is covered in detail. The derivation and implementation of a cognitive-behavioral treatment program specifically for depressed OCD patients is described and illustrated using a case example.

The OCI-CV-R: A Revision of the Obsessive-Compulsive Inventory - Child Version.

BACKGROUND: The Obsessive-Compulsive Inventory-Children's Version (OCI-CV) was developed to assess obsessive-compulsive symptoms in youth. Recent changes in the Diagnostic and Statistical Manual (DSM-5) exclude hoarding from inclusion in the diagnosis of obsessive-compulsive disorder (OCD). Accordingly, the present study examined the reliability, validity, factorial structure, and diagnostic sensitivity of a revised version of the scale - the OCI-CV-R- that excludes items assessing hoarding. METHODS: Participant were 1047 youth, including 489 meeting DSM criteria for primary OCD, 298 clinical controls, and 260 nonclinical controls, who completed the OCI-CV and measures of obsessive-compulsive symptom severity, depression, and anxiety at various treatment and research centers. RESULTS: Findings support a five-factor structure (doubting/checking, obsessing, washing, ordering, and neutralizing), with a higher order factor. Factorial invariance was found for older (12-17 years) and younger (7-11 years) children. Internal consistency of the OCI-CV-R was acceptable, and discriminant and convergent validity were adequate and akin to that of its progenitor. Diagnostic sensitivity and specificity were found for a total score of 8 and higher. CONCLUSION: It is recommended that the OCI-CV-R replace the former version, and that this measure serve as part of a comprehensive clinical assessment of youth with OCD. Recommendations for further research with ethnically and racially diverse samples, as well as the need to establish benchmark scores are discussed.

GIV CARE: A Group Intervention to Reduce Accommodation Among Relatives of Individuals With Fear-Based Disorders.

Fear-based disorders (FBDs) occur in an interpersonal context as relatives (e.g., partners, parents) often accommodate symptoms. Symptom accommodation, which is ubiquitous and reinforces FBD behavior, is associated with increased FBD symptom severity and interferes with treatment. Accordingly, reducing accommodation represents a crucial aim for intervention. We describe a brief, manualized group intervention to decrease symptom accommodation and caregiver burden among cohabitating relatives of individuals with FBDs. The intervention is the first to date that (a) jointly includes parents and partners to target symptom accommodation, and (b) uses a transdiagnostic group treatment approach. We also provide preliminary empirical support for this group-based intervention among adult relatives (N = 20) that participated in the five weekly intervention sessions and completed assessments at baseline, posttreatment, and 1-month follow-up (1MFU). Preliminary results suggest that the group intervention is feasible and acceptable. Completers (n = 18) exhibited significant reductions in symptom accommodation and self-reported burden between baseline and 1MFU. The discussion identifies study limitations and future directions.

Predicting COVID-19-related anxiety: The role of obsessive-compulsive symptom dimensions, anxiety sensitivity, and body vigilance.

The novel coronavirus disease (COVID-19), first detected in December of 2019 and declared a global pandemic in March of 2020, continues to pose a serious threat to public health and safety worldwide. Many individuals report anxiety in response to this threat, and at high levels, such anxiety can result in adverse mental health outcomes and maladaptive behavioral responses that have consequences for the health of communities more broadly. Predictors of excessive anxiety in response to COVID-19 are understudied. Accordingly, the present study examined psychological factors that predict more intense COVID-19-related anxiety. 438 community members completed measures assessing COVID-19-related anxiety as well as psychological variables hypothesized to predict anxious responding to the threat of COVID-19. As expected, obsessive-compulsive symptoms related to contamination, the fear of arousal-related body sensations (i.e., anxiety sensitivity), and body vigilance each predicted more severe anxiety related to the pandemic. Obsessive-compulsive symptoms related to responsibility for causing harm also emerged as a predictor. Study limitations and implications are discussed.

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.

Better Together: A Review and Recommendations to Optimize Research on Family Involvement in CBT for Anxiety and Related Disorders.

Anxiety and related disorders (ARDs) occur in an interpersonal context. Individuals with ARDs respond well to individual cognitive behavioral therapy (CBT); however, there is room for improvement. As such, family members may be included to "enhance" treatment outcomes, yet findings from studies examining family involvement in CBT for ARDs are equivocal. The present paper (a) identifies methodological considerations for explaining inconsistent outcomes among CBT for ARDs with family involvement, and (b) reviews factors that affect outcomes of CBT for ARDs with family involvement including levels of involvement in treatment (e.g., number, duration, and spacing of sessions) and characteristics of who is involved in treatment (e.g., family member cognitions and cultural factors). Limitations of the literature and recommendations for future research are discussed. Researchers should focus on conducting studies that can test not whether but for whom and how family involvement can contribute to improved outcomes above and beyond individual CBT for ARDs.

The OCI-12: A syndromally valid modification of the obsessive-compulsive inventory-revised.

The 18-item Obsessive-Compulsive Inventory-Revised (OCI-R) is a widely used self-report measure of Obsessive-Compulsive Disorder (OCD) symptoms, yet its factor structure does not converge with contemporary dimensional models of OCD symptoms. In addition to assessing the four core OCD dimensions, the OCI-R includes hoarding and neutralizing factors. However, since its publication, hoarding has been designated as a separate disorder, and there are concerns about the neutralizing factor's reliability and validity. The aim of this study was to evaluate a syndromally valid modification of the OCI-R. Adult samples of individuals diagnosed with OCD (n = 1087), anxiety related disorders (n = 1306), and unselected community volunteers (n = 423) completed the OCI-R and measures of anxiety and mood. Analyses excluded the 3 OCI-R hoarding items and suggested the removal of the 3 neutralizing items. Internal consistency, sensitivity and specificity to OCD clinical status, test-retest reliability, sensitivity to treatment, and convergent and discriminant validity were evaluated for the resultant 12-item scale (termed the OCI-12). The OCI-12 evidenced good to excellent psychometric properties. Clinical norms, severity benchmarks, and a clinical cutoff score were computed. In conclusion, the OCI-12 represents a syndromally valid update of the OCI-R with comparable psychometric properties and superior sensitivity and specificity.

The OCI-4: An ultra-brief screening scale for obsessive-compulsive disorder.

Obsessive-compulsive disorder (OCD) is a prevalent and burdensome condition that is typically assessed using in-depth interviews or lengthy self-report measures. Accordingly, routine screening in busy non-mental health settings is impractical, and OCD is often under- (or mis-) recognized. We evaluated an ultra-brief version of a widely used self-report measure, the Obsessive-Compulsive Inventory-Revised (OCI-R), which may be employed as a routine screener for OCD. A total of 1087 adults diagnosed with OCD, 1306 unselected adults from the community, and 423 adults with anxiety related disorders completed the OCI-R along with measures of anxiety and mood. Analyses were conducted to reduce the number of items and examine evidence for sensitivity and specificity to OCD clinical status, test-retest reliability, sensitivity to treatment, and convergent and discriminant validity. Four items that optimally assess different dimensions of OCD (washing, checking, ordering, obsessing) were identified. Psychometric evaluation revealed good to excellent test-retest reliability, validity, prediction of clinical OCD status, and sensitivity to treatment. A 4-item version of the OCI-R, called the OCI-4, shows promise as an ultra-brief screening tool for identifying likely OCD in settings where in-depth assessment is impractical. Patients with a positive screen may be referred for further evaluation and appropriate treatment.