Abstract task sequence initiation deficit dissociates anxiety disorders from obsessive-compulsive disorder and healthy controls.

In everyday life, humans perform sequences of tasks. These tasks may be disrupted in people with obsessive-compulsive disorder (OCD). Symptoms, such as compulsions, can be considered sequential and often cause repetitions of tasks that disrupt daily living (e.g., checking the stove while cooking). Motor sequences have been used to study behavioral deficits in OCD. However, not all sequences are motor sequences. Some are more "abstract" in that they are composed of a series of tasks (e.g., chopping and stirring) rather than being dependent on individual actions or stimuli. These abstract task sequences require cognitive control mechanisms for their execution. Although theory has proposed deficits in these sequences in OCD as well, they have not been directly investigated. We tested the hypotheses that OCD participants exhibit deficits in the control mechanisms specific to abstract task sequences and more general flexible behavior (measured with task switching within the sequences), relative to health controls (HCs) and clinical controls (participants with anxiety disorders [ANX]). A total of 112 participants completed abstract task sequences consisting of simple categorization tasks. Surprisingly, participants with OCD did not perform worse than HCs or ANX. However, ANX participants showed impairments specific to sequential control that did not extend to more general flexible control. Thus, we showed a novel behavioral dissociation between OCD and ANX specific to abstract task sequential control. These results also implicate deficits in specific frontal sequential control neural circuitry in ANX and not in OCD, where implicit sequential deficits may more closely align with striatal circuits.

Course and clinical correlates of obsessive-compulsive disorder with or without comorbid personality disorder.

BACKGROUND: Personality disorders (PDs) are often comorbid with obsessive-compulsive disorder (OCD) which may influence symptom presentation and course. This investigation sought to examine the impact of comorbid PDs on clinical presentation and symptom chronicity in a large, prospective longitudinal OCD study. METHODS: Participants (n = 263) were treatment-seeking adults with a primary diagnosis of OCD separated into two groups: individuals with and without a co-occurring PD. We conducted two-tailed t-tests to compare symptom severity, functioning, and quality of life between the OCD + PD group (n = 117) and the OCD w/o PD group (n = 146). Chronicity analyses were conducted to compare the amount of time in-episode for OCD and major depressive disorder (MDD) between the two groups. RESULTS: The OCD + PD group reported greater OCD and depression severity, lower levels of psychosocial functioning and worse quality of life than the OCD w/o PD group. The OCD + PD group exhibited greater OCD and MDD symptom chronicity; over 5 years the OCD + PD group spent 16.2 % weeks longer at full criteria for OCD and three times as many weeks in episode for MDD than the OCD w/o PD group. LIMITATIONS: Focusing on PDs as a group limited our ability to make observations about specific PDs. Further, the participants in our sample were predominantly White and all were treatment seeking which limits the generalizability of our findings. CONCLUSIONS: Our results suggest that those with OCD and comorbid PDs present with greater overall impairment and may require additional considerations during treatment conceptualization and planning.

The relationship between obsessive-compulsive disorder symptom subtypes and social adjustment.

Background: Although it has been widely established that poor social functioning is a characteristic of obsessive-compulsive disorder (OCD), little research has examined the relationship between OCD symptom subtypes and domains of social functioning. Thus, the present study sought to examine the specific ways in which impairment in social adjustment occurs in each symptom subtype of OCD. Methods: A total of 325 adult participants with a primary diagnosis of OCD were included in the study. Hierarchical linear regressions were used to compare the extent to which OCD symptom subtypes predicted social adjustment domains after controlling for OCD and depression severity. Results: Hoarding was shown to be significantly associated with work functioning. Whereas both contamination and symmetry subtypes were significantly associated with social functioning, only the contamination subtype was associated with functioning within the family unit. The symptom subtypes of doubt and taboo thoughts were not significantly associated with any domains of social adjustment. Conclusion: Consistent with previous research, our results suggest a differential impact of OCD symptom subtypes on social adjustment. They offer important implications for the specific domains to target in treatment for different symptom subtypes.

Directionality of change in obsessive compulsive disorder and depression over six years of prospective follow-up.

Major Depressive Disorder (MDD) is often comorbid with obsessive-compulsive disorder (OCD) yet little is known about the directionality of the association between OCD and depression symptoms. We aim to investigate the effect OCD symptoms has on depression symptoms and vice versa over an extended period of time. This is one of the first longitudinal studies to evaluate the relationship between OCD and depression in a large clinical sample. Participants (n = 324) were treatment-seeking adults with a primary diagnosis of OCD. OCD and depression symptoms were assessed annually over the six-year follow-up period. Random intercepts cross-lagged panel models (RI-CLPM) were conducted to compare unidirectional and bidirectional models over time. The best-fitting and most parsimonious model included paths with OCD symptoms predicting depression symptoms, but not vice versa. OCD symptom severity in a given year predicted next year depression severity. However, depression severity did not predict next-year OCD symptom severity in this sample. Our results suggest that depression severity may be secondary to OCD symptoms and treating OCD should be prioritized over treating depression.

Characteristics Associated With Loneliness and Coping Skills Utilization During the COVID-19 Pandemic.

Although stay-at-home orders and physical distancing measures are vital to managing the COVID-19 outbreak, there is concern these limitations on in-person contact may increase feelings of loneliness. The present study examined loneliness in relation to living situation, psychiatric symptoms, and coping skills utilization during the COVID-19 pandemic. The aim was to identify demographic and psychological factors that may contribute to greater feelings of loneliness. A sample of 125 adults (18 years and older) completed measures on loneliness, psychiatric symptoms, and coping skills in September 2020. Multiple regression analysis indicated living situation moderates the relationship between hours spent having remote conversations and loneliness. Remote conversation hours were associated with decreased loneliness in those living alone but was not associated with loneliness in those living with others. Multivariate regression analysis indicated that substance use and self-blame were associated with increased loneliness whereas the use of emotional support to cope with pandemic-related stress was associated with decreased loneliness. The current study highlights the importance of finding alternative ways to remain socially connected, particularly for those living alone. Increasing access to videoconferencing technology and promoting help-seeking behaviors may be a promising approach to manage loneliness during times of increased social isolation.

Personality traits as predictors of OCD remission: A longitudinal study.

BACKGROUND: Personality traits may confer vulnerability to psychopathology. However, few studies have examined the association between personality traits and obsessive-compulsive disorder (OCD) course. The present study investigates personality traits, OCD symptom severity, and illness duration as a predictor of OCD remission. METHODS: 166 treatment-seeking adults with OCD, recruited as part of the Brown Longitudinal Obsessive-Compulsive Study, completed the NEO Five-Factor Inventory 3 (NEO-FFI) and were in episode for OCD at time of NEO-FFI completion. Participants were followed for up to 3 years. RESULTS: Results suggest individuals with OCD had a 21 % likelihood of reaching remission over the course of 3 years. Greater OCD symptom severity and longer illness duration were associated with a decreased likelihood of remission. Among the five factors of personality, only low extraversion was associated with a decreased rate of remission. Neuroticism, openness, agreeableness, and conscientiousness were not associated with remission. LIMITATIONS: As this was an observational study, treatment was not controlled precluding examination of treatment on course. Further, data collected on age of onset and symptom severity during follow up were retrospective and therefore are also subject to recall bias. CONCLUSIONS: Our findings provide preliminary support that personality traits are potential factors impacting course and symptom presentation. Future research is necessary to determine the mechanisms in which personality traits may influence the presentation and course of OCD.

Behavioral Therapy Teams for Obsessive-Compulsive Disorder: Lessons Learned From a Pilot Randomized Trial in a Community Mental Health Center.

Community mental health centers (CMHCs) provide the majority of mental health services for low-income individuals in the United States. Exposure and response prevention (ERP), the psychotherapy of choice for obsessive-compulsive disorder (OCD), is rarely delivered in CMHCs. This study aimed to establish the acceptability and feasibility of testing a behavioral therapy team (BTT) intervention to deliver ERP in CMHCs. BTT consisted of individual information-gathering sessions followed by 12 weeks of group ERP and concurrent home-based coaching sessions. The sample consisted of 47 low-income individuals with OCD who were randomized to receive BTT or treatment as usual (TAU). Symptom severity and quality-of-life measures were assessed at pretreatment, posttreatment, and 3- and 6-month posttreatment. Feasibility of training CMHC staff was partially successful. CMHC therapists successfully completed rigorous training and delivered ERP with high fidelity. However, training paraprofessionals as ERP coaches was more challenging. ERP was feasible and acceptable to patients. BTT participants were more likely than TAU participants to attend their first therapy session and attended significantly more treatment sessions. A large between-group effect size was observed for reduction in OCD symptoms at posttreatment but differences were not maintained across 3- and 6-month follow-ups. For BTT participants, within-group effect sizes reflecting change from baseline to posttreatment were large. For TAU participants, depression scores did not change during the active treatment phase but gradually improved during follow-up. Results support feasibility and acceptability of ERP for this patient population. Findings also underscore the importance of implementation frameworks to help understand factors that impact training professionals.

Impact of the peripartum period on the longitudinal course of obsessive-compulsive disorder.

Some women are vulnerable to developing new onset obsessive-compulsive disorder (OCD) or having an exacerbation of pre-existing OCD during reproductive cycle events. Reports on the impact of the peripartum period on pre-existing OCD are inconsistent, with both worsening and improving symptom severity described. Studies have primarily been retrospective or have collected few data points, which limits the investigators' ability to capture the range of OCD symptoms during this time period, systematically and prospectively. The objective of this investigation was to add to the existing literature on the impact of the peripartum period on the course of pre-existing OCD. We conducted a secondary analysis of a subset data from the Brown Longitudinal Obsessive Compulsive Study, a prospective, observational study of OCD course. Nineteen women who experienced a pregnancy during the course of the study (9.5% of overall sample of women) were followed on average for 486 ± 133 weeks. Weekly psychiatric status ratings (PSRs) of OCD severity were compared between peripartum and non-peripartum periods. We found that the peripartum period did not significantly impact the course of OCD severity in the majority of women (N = 13, 69%). Of the minority of women with measurable variability in OCD symptoms, no statistically significant difference in PSR scores was observed between peripartum and non-peripartum periods. In this novel yet small dataset, the severity of OCD does not appear to worsen for most women during the peripartum period.

Comparison of the Association Between Goal-Directed Planning and Self-reported Compulsivity vs Obsessive-Compulsive Disorder Diagnosis.

Importance: Dimensional definitions of transdiagnostic mental health problems have been suggested as an alternative to categorical diagnoses, having the advantage of capturing heterogeneity within diagnostic categories and similarity across them and bridging more naturally psychological and neural substrates. Objective: To examine whether a self-reported compulsivity dimension has a stronger association with goal-directed and related higher-order cognitive deficits compared with a diagnosis of obsessive-compulsive disorder (OCD). Design, Setting, and Participants: In this cross-sectional study, patients with OCD and/or generalized anxiety disorder (GAD) from across the United States completed a telephone-based diagnostic interview by a trained rater, internet-based cognitive testing, and self-reported clinical assessments from October 8, 2015, to October 1, 2017. Follow-up data were collected to test for replicability. Main Outcomes and Measures: Performance was measured on a test of goal-directed planning and cognitive flexibility (Wisconsin Card Sorting Test [WCST]) and a test of abstract reasoning. Clinical variables included DSM-5 diagnosis of OCD and GAD and 3 psychiatric symptom dimensions (general distress, compulsivity, and obsessionality) derived from a factor analysis. Results: Of 285 individuals in the analysis (mean [SD] age, 32 [12] years; age range, 18-77 years; 219 [76.8%] female), 111 had OCD; 82, GAD; and 92, OCD and GAD. A diagnosis of OCD was not associated with goal-directed performance compared with GAD at baseline (ß [SE], -0.02 [0.02]; P = .18). In contrast, a compulsivity dimension was negatively associated with goal-directed performance (ß [SE], -0.05 [0.02]; P = .003). Results for abstract reasoning task and WCST mirrored this pattern; the compulsivity dimension was associated with abstract reasoning (ß [SE], 2.99 [0.63]; P < .001) and several indicators of WCST performance (eg, categories completed: ß [SE], -0.57 [0.09]; P < .001), whereas OCD diagnosis was not (abstract reasoning: ß [SE], 0.39 [0.66]; P = .56; categories completed: ß [SE], -0.09 [0.10]; P = .38). Other symptom dimensions relevant to OCD, obsessionality, and general distress had no reliable association with goal-directed performance, WCST, or abstract reasoning. Obsessionality had a positive association with requiring more trials to reach the first category on the WCST at baseline (ß [SE], 2.92 [1.39]; P = .04), and general distress was associated with impaired goal-directed performance at baseline (ß [SE],-0.04 [0.02]; P = .01). However, unlike the key results of this study, neither survived correction for multiple comparisons or was replicated at follow-up testing. Conclusions and Relevance: Deficits in goal-directed planning in OCD may be more strongly associated with a compulsivity dimension than with OCD diagnosis. This result may have implications for research assessing the association between brain mechanisms and clinical manifestations and for understanding the structure of mental illness.

Directionality of change in obsessive compulsive disorder (OCD) and suicidal ideation over six years in a naturalistic clinical sample✰.

BACKGROUND: Obsessive compulsive disorder (OCD) is associated with elevated suicide risk, but the directionality of the association between OCD severity and suicidal ideation has not been established, which was the goal of this study. METHODS: Participants (n = 325) were adults with either a current or past diagnosis of Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) OCD who were assessed annually for suicidal ideation and OCD symptom severity for six years. Cross-lagged panel analyses statistically compared unidirectional and bidirectional models over time. Serious suicide-related adverse events were reported. RESULTS: The best-fitting and most parsimonious model included paths predicting suicidal ideation from OCD symptom severity, but not vice versa. These results were confirmed by comparing a model with cross-lagged paths constrained equal to a freely estimated model. Higher OCD symptom severity in a given year was associated with a higher suicidal ideation severity in the subsequent year. Five suicide-related adverse events were reported throughout the duration of the study, including two suicide deaths and three suicide attempts. LIMITATIONS: The study relied on a single-item, annual measure of suicidal ideation in adults, with substantial variability in severity of suicide risk, and missing data increased with later observations in the study. DISCUSSION: OCD symptom severity predicted next year suicidal ideation severity. In contrast, suicidal ideation severity in a given year did not predict next-year OCD symptom severity in this OCD sample. Thus, rather than waiting for suicidal ideation to resolve, clinicians should consider providing empirically supported treatments for OCD.

Exposure and Response Prevention in the Treatment of Obsessive-Compulsive Disorder: Current Perspectives.

Numerous clinical trials support the efficacy of exposure and response prevention (ERP) for the treatment of obsessive-compulsive disorder (OCD). Accordingly, ERP has been formally recognized as a first-line, evidence-based treatment for OCD. This review discusses the theoretical underpinnings of the treatment from a behavioral and neurobiological perspective and summarizes the evidence supporting the efficacy of ERP across child and adult populations. Next, we discuss predictors of ERP treatment outcome and discuss implementation strategies designed to improve feasibility and adoption. Finally, strategies to improve treatment dissemination are discussed.

Introduction to the Special Issue on Cognitive and Behavioral Flexibility in Fear and Anxiety Disorders.

Converging lines of research highlight the significance of cognitive and behavioral flexibility in the etiology, maintenance, and treatment of fear and anxiety disorders. We have developed a Special Issue to highlight recent empirical investigations, contemporary theory, and novel directions for future study. It is hoped that this special issue will (a) underscore the centrality of cognitive and behavioral flexibility to fear- and anxiety-related psychopathology, (b) call attention to cognitive science approaches investigating related neuropsychological correlates, and (c) highlight novel experimental and theoretical research on germane contextual factors.

The Brown Incompleteness Scale (BINCS): Measure development and initial evaluation.

BACKGROUND: In recent years, incompleteness has received increased clinical attention as a core motivation underlying obsessive-compulsive spectrum disorders. Yet, assessment of incompleteness has relied almost exclusively on self-report and has assumed a unitary conceptualization of this phenomenon. Therefore, we sought to develop and validate a new multi-faceted clinician-administered measure of incompleteness. The Brown Incompleteness Scale (BINCS) consists of 21 items; each rated on a 5-point scale, with higher scores indicating a greater degree of incompleteness. The current study describes the measure's development and preliminary validation. METHODS: The scale was administered to 100 consecutive participants who were part of a longitudinal follow-up study of OCD. The reliability, validity, and factor analytic structure of the scale were evaluated. RESULTS: Exploratory factor analysis supported a two-factor solution, which can best be described as representing both behavioral and sensory manifestations of incompleteness. CONCLUSIONS: The BINCS demonstrated strong internal consistency as well as convergent and divergent validity. This clinician-administered scale will provide a more comprehensive clinical assessment of patients with incompleteness.

Unified protocol for the discontinuation of long-term serotonin reuptake inhibitors in obsessive compulsive disorder: Study protocol and methods.

Obsessive-compulsive disorder (OCD) is chronic psychiatric disorder associated with high rates of functional impairment and decreased quality of life. Although serotonin reuptake inhibitors have demonstrated efficacy in the treatment of OCD, little data is available to guide clinicians on how to manage these medications long-term. Cognitive-behavioral approaches provide a promising avenue for helping OCD patients discontinue maintenance SRIs while minimizing the potential for symptom worsening. This manuscript describes the rationale and methods for pilot feasibility study designed to a unified, cognitive-behavioral strategy for discontinuing long-term SRIs in OCD. The aims of the study are (1) to evaluate the feasibility and acceptability of research procedures and interventions, (2) to test the efficacy of this treatment relative to an enhanced control condition and (3) to investigate the role of distress tolerance in both taper completion and clinical outcome. Our central aim is to investigate whether this approach improves discontinue outcomes relative to an enhanced control condition. Identifying optimal long-term treatment strategies for this population is needed to guide clinicians managing this often-chronic disorder.

The impact of lifetime PTSD on the seven-year course and clinical characteristics of OCD.

Research has suggested that the co-occurrence of PTSD in individuals with OCD is associated with more severe symptoms and less responsivity to empirically supported treatment as compared to individuals with OCD and no history of PTSD. However, much of this work has been limited by non-empirical case report design, cross-sectional and retrospective analyses, or small sample sizes. The current study extended this research by comparing the clinical characteristics of individuals with OCD with and without a lifetime PTSD diagnosis in a large, naturalistic, longitudinal sample over the course of seven years. At baseline, individuals with comorbid lifetime PTSD reported significantly more severe symptoms of OCD (including symptom levels and insight), lower quality of life, and higher rates of comorbid lifetime mood and substance use disorders than participants without lifetime PTSD. Further, individuals with comorbid OCD and lifetime PTSD reported significantly more severe OCD symptoms over the course of seven years than those without lifetime PTSD. These results are largely consistent with the existing literature and support the need to consider PTSD symptoms in the assessment and treatment of OCD.

App-guided exposure and response prevention for obsessive compulsive disorder: an open pilot trial.

Although effective treatments for obsessive-compulsive disorder (OCD) exist, there are significant barriers to receiving evidence-based care. Mobile health applications (Apps) offer a promising way of overcoming these barriers by increasing access to treatment. The current study investigated the feasibility, acceptability, and preliminary efficacy of LiveOCDFree, an App designed to help OCD patients conduct exposure and response prevention (ERP). Twenty-one participants with mild to moderate symptoms of OCD were enrolled in a 12-week open trial of App-guided self-help ERP. Self-report assessments of OCD, depression, anxiety, and quality of life were completed at baseline, mid-treatment, and post-treatment. App-guided ERP was a feasible and acceptable self-help intervention for individuals with OCD, with high rates of retention and satisfaction. Participants reported significant improvement in OCD and anxiety symptoms pre- to post-treatment. Findings suggest that LiveOCDFree is a feasible and acceptable self-help intervention for OCD. Preliminary efficacy results are encouraging and point to the potential utility of mobile Apps in expanding the reach of existing empirically supported treatments.

A cross-cultural clinical comparison between subjects with obsessive-compulsive disorder from the United States and Brazil.

Although OCD is a global problem, the literature comparing, in a direct and standardized way, the manifestations across countries is scarce. Therefore, questions remain as to whether some important clinical findings are replicable worldwide, especially in the developing world. The objective of this study was to perform a clinical comparison of OCD patients recruited in the United States (U.S.) and Brazil. Our sample consisted of 1187 adult, treatment-seeking OCD outpatients from the U.S. (n=236) and Brazil (n=951). With regards to the demographics, U.S. participants with OCD were older, more likely to identify as Caucasian, had achieved a higher educational level, and were less likely to be partnered when compared to Brazilians. Concerning the clinical variables, after controlling for demographics the two samples presented largely similar profiles. Brazilian participants with OCD, however, endorsed significantly greater rates of generalized anxiety disorder and post-traumatic stress disorder, whereas U.S. subjects were significantly more likely to endorse a lifetime history of addiction (alcohol-use and substance-use disorders). This is the largest direct cross-cultural comparison to date in the OCD field. Our results provide much needed insight regarding the development of culture-sensitive treatments.

Symptom subtype and quality of life in obsessive-compulsive disorder.

Quality of life (QoL) is significantly impaired in OCD across several facets of life, such as social, occupational, and family functioning, subjective sense of well-being, and enjoyment of leisure activities. The present study examined the relationship between 5 symptom subtypes of OCD (contamination, symmetry, hoarding, overresponsibility for harm, and taboo) and QoL. Participants were 325 adults with OCD enrolled in the Brown Longitudinal Obsessive Compulsive Study. Hierarchical linear regression analyses indicated hoarding, contamination, symmetry, and overresponsibility for harm were associated with impairment in household functioning, enjoyment of leisure activities, social relationships, and physical health. The implications of these findings are discussed.

Identification and management of eating disorders in gynecology: menstrual health as an underutilized screening tool.

Eating disorders are life-threatening conditions that disproportionately affect females, often during child-bearing years. Although the endocrinological and reproductive sequelae of these conditions often fall within the treatment purview of obstetrician-gynecologists, the assessment of eating pathology is challenging and often not part of routine clinical care. This commentary focuses on one of the common presenting symptoms of eating disorders in women, menstrual dysfunction, and discusses considerations for its clinical management in gynecology. Assessment of menstrual status provides a natural starting point for provider-patient discussion of disordered eating and weight behavior. Routine screening for eating disorders is critical and must be universal given the serious long-term consequences of these disorders.

An empirical investigation of incompleteness in a large clinical sample of obsessive compulsive disorder.

Obsessive Compulsive Disorder (OCD) is a disorder with heterogeneous clinical presentations. To advance our understanding of this heterogeneity we investigated the prevalence and clinical features associated with incompleteness (INC), a putative underlying core feature of OCD. We predicted INC would be prominent in individuals with OCD and associated with greater severity and impairment. We examined the impact of INC in 307 adults with primary OCD. Participants with clinically significant INC (22.8% of the sample) had significantly greater OCD severity, greater rates of comorbidity, poorer ratings of functioning, lower quality of life, and higher rates of unemployment and disability. Participants with clinically significant INC were also more likely to be diagnosed with OCPD and to endorse symmetry/exactness obsessions and ordering/arranging compulsions than those who reported low INC. Our findings provide evidence that INC is associated with greater severity, comorbidity, and impairment, highlighting the need for improved assessment and treatment of INC in OCD.