Efficacy of metacognitive training for depression as add-on intervention for patients with depression in acute intensive psychiatric inpatient care: A randomized controlled trial.

BACKGROUND: Metacognitive training for depression (D-MCT) is a novel low-intensity group training for economic treatment of depression. Previous studies demonstrate its efficacy in moderately depressed outpatients. The present study evaluated efficacy and patients' perspective of the D-MCT in severely depressed psychiatric inpatients. METHODS: In a randomized-controlled trial, 75 individuals with a major depressive disorder (MDD) were allocated to D-MCT versus euthymic therapy as add-on (twice a week) to cognitive-behavioural-based (CBT) inpatient-care. Depressive symptoms (HDRS, BDI), dysfunctional (meta)cognition (DAS, MCQ-30) and subjective appraisal were assessed at baseline, 4 weeks (post) and 3 months (follow-up). RESULTS: Participants in both conditions showed a large decline in depression at post and follow-up-assessment. No superior add-effect of D-MCT versus active control emerged for depression severity on top of the inpatient care. However, among patients with a diagnosis of MDD with no (vs. at least one) comorbidity, D-MCT participants showed a larger decline in depressive (meta-)cognition at follow-up with medium-to-large effect sizes. D-MCT was evaluated as superior in overall appraisal, treatment preference, motivation and satisfaction. LIMITATIONS: The follow-up time interval of 3 months may have been too short to detect long-term effects. There is emerging evidence that modification of (meta)cognition unfolds its full effects only with time. Effects of CBT inpatient-care on outcome parameters cannot be differentiated. CONCLUSIONS: Although D-MCT as an add-on was not superior in complete case analyses, results suggest greater benefit for patients with MDD and no comorbidity. D-MCT proved feasible in acute-psychiatric inpatient-care and was highly accepted by patients. Future studies should investigate the role of modified (meta)cognition on long-term treatment outcome, including dropout and relapse rates.

Neurocognitive Functioning in Alcohol Use Disorder: Cognitive Test Results Do not Tell the Whole Story.

OBJECTIVES: It is textbook knowledge that individuals with alcohol use disorder (AUD) show large neurocognitive deficits. However, these patients display a number of additional impairments (e.g., lack of drive and motivation) that may contribute to poor test results. The impact of these secondary mediators has not been explored systematically. Based on prior findings that low performance motivation, a negative attitude toward cognitive assessment, and momentary symptoms compromise neuropsychological test results in depression, schizophrenia, and obsessive-compulsive disorder, we examined the possibility that impaired test results in AUD partially represent an epiphenomenon. METHODS: Fifteen patients with AUD and 20 matched nonclinical individuals underwent a comprehensive neuropsychological test battery. The neurocognitive assessment was flanked by the Momentary Influences, Attitudes and Motivation Impact on Cognitive Performance Scale (MIAMI), which captures momentary influences affecting performance. RESULTS: Patients with AUD performed worse than nonclinical controls on most test parameters. Group differences achieved a very large effect size for parameters tapping speed and accuracy. Patients with AUD showed deviant scores, particularly on the post version of the MIAMI (retrospective assessment of symptoms and influences during testing) and the total scores. For accuracy, the MIAMI scores represented a partial mediator. For speed, significant group effect sizes were rendered nonsignificant when the MIAMI was taken into account. CONCLUSION: Like other psychiatric patients, patients with AUD show marked neurocognitive impairments that seem to be aggravated by, for example, distraction and lack of effort. This tentatively suggests that performance only partly reflects cortical impairments in areas hosting neurocognitive faculties. Contextual factors deserve greater attention in patients with addiction. The cross-sectional design of our study limits conclusions relating to causality.

If it is absurd, then why do you do it? The richer the obsessional experience, the more compelling the compulsion.

Mounting evidence suggests that obsessive intrusions are often accompanied and amplified by perceptual experiences of different modalities (e.g., feeling dirt on one's skin while experiencing intrusive thoughts about contamination). Pilot studies conducted online with individuals endorsing mild obsessive-compulsive symptoms have linked the co-occurrence of perceptual experiences and obsessions to the severity of subsequent compulsive behaviour as well as low insight. However, it is presently unclear whether sensory experiences accompany all types of obsessional thoughts or are restricted to certain preoccupations (e.g., contamination and aggression). The present study examined a clinical inpatient and outpatient sample with a formally diagnosed obsessive-compulsive disorder (N = 34). Perceptual properties of intrusive thoughts were assessed with the Sensory Properties of Obsessions Questionnaire. The prevalence of perception-laden obsessive thoughts was comparable with prior studies (73.5%), but the intensity was significantly greater. No association was observed between perceptual experiences and expert-rated insight. However, the severity of perception-laden obsessions predicted the frequency of and impairment associated with compulsive behaviour. This was particularly strong for obsessions about contamination. The present study confirms the high prevalence and clinical relevance of perceptual experiences that accompany obsessions and further challenges the traditional trichotomy splitting mental phenomena into thoughts, intrusions, and hallucinations.

Perceptual properties of obsessive thoughts are associated with low insight in obsessive-compulsive disorder.

Obsessions are traditionally defined as bothersome and repetitive thoughts that the patient is unable to resist. Preliminary evidence suggests that in a subgroup of patients with obsessive-compulsive disorder (OCD), obsessions are experienced as partially perceptual. The present study explored the frequency of perceptually laden obsessions and their relationship with illness insight and depression. Twenty-six patients with OCD were administered the newly developed Sensory Properties of Obsessions Questionnaire. Participants were asked to endorse on a 5-point Likert scale whether their obsessions were associated with perceptual features. Participants showed moderate symptom severity. A total of 73% affirmed that their obsessions contained perceptual features. The predominant perceptual channels were visual, tactile, and somatic (i.e., bodily sensations). The extent of perceptual aspects associated with obsessions was strongly correlated with lack of insight (Yale-Brown Obsessive-Compulsive Scale item 11) but not depression severity. The present study suggests that obsessive thoughts are frequently accompanied by perceptual sensations, which concurs with models assuming a continuum between hallucinations and intrusions. Apparently, the more "real" or authentic the obsessive thought is experienced, the less the afflicted person is able to dismiss its content as fully irrational or absurd.

The more it is needed, the less it is wanted: attitudes toward face-to-face intervention among depressed patients undergoing online treatment.

Many individuals suffering from depression do not actively seek treatment. Self-help strategies represent low-threshold treatment options that are particularly relevant for milder cases. The present study addressed two important issues: (1) we examined depressed individuals' motives and attitudes that may represent barriers to face-to-face treatment; (2) we examined if the participation in an online treatment program facilitates or compromises their willingness to undergo face-to-face treatment. We recruited 210 participants with depression for a trial on the efficacy of an online treatment program for depression. Participants were randomly allocated either to a self-help treatment (Deprexis) or to a wait-list control group. All participants filled out a newly developed 42-item questionnaire called Psychotherapy Expectations, Concerns, and Hopes Inventory (PECHI). The scale measures attitudes toward face-to-face treatment and was administered at baseline and 8 weeks later. Principal component analysis of the PECHI revealed five dimensions: hope for symptomatic improvement, fear of poor alliance with the therapist, skill acquisition, skepticism and resentment of psychotherapy, and self-stigma. Attitudes toward treatment were stable over time and neither modulated by group status nor by self-reported or objective symptom decline. Correlation analyses revealed that current levels of depression and well-being were potent predictors of attitudes toward treatment, suggesting that when the patient feels more depressed, doubts about the effectiveness of therapy emerge more strongly. To conclude, results suggest that Deprexis neither promotes nor reduces negative attitudes toward psychotherapy, nor does it increase barriers to enter face-to-face treatments. An alarming paradox emerged: when a depressed person is in greatest need of help, motivation to seek face-to-face treatment is lowest.

Veridical and false memory for scenic material in posttraumatic stress disorder.

The question whether memory aberrations in posttraumatic stress disorder (PTSD) also manifest as an increased production of false memories is important for both theoretical and practical reasons, but is yet unsolved. Therefore, for the present study we investigated veridical and false recognition in PTSD with a new scenic variant of the Deese-Roediger-McDermott (DRM) paradigm, which was administered to traumatized individuals with PTSD (n=32), traumatized individuals without PTSD (n=30), and non-traumatized controls (n=30). The PTSD group neither produced higher rates of false memories nor expressed more confidence in errors, but did show inferior memory sensitivity. Whereas depressive symptoms did not correlate with veridical nor false recognition, state dissociation was positively associated with false memories.

How to treat the untreated: effectiveness of a self-help metacognitive training program (myMCT) for obsessive-compulsive disorder.

Despite advances in the understanding and treatment of obsessive-compulsive disorder (OCD), many patients undergoing interventions display incomplete symptom reduction, Our research group has developed a self-help manual entitled "My Metacognitive Training for OCD" (myMCT) aimed at raising patients' awareness about cognitive biases that seem to subserve OCD. The training is particularly intended for patients currently unable or unwilling to attend standard therapy, or in cases where such a treatment option is not available. For the present study, 86 individuals suffering from OCD were recruited over the Internet. Following the initial assessment, participants were either immediately emailed the myMCT manual or allocated to a waitlist group. After 4 weeks, a second assessment was performed, The myMCT group showed significantly greater improvement for OCD symptoms according to the Y-BOCS total score compared with the waitlist group (d = .63), particularly for obsessions (d= .69). Medium to strong differences emerged for the OCI-R (d = .70) and the BDI-SF (d = .50). The investigation provides the first evidence for the effectiveness of the myMCT for OCD.

Generic and illness-specific quality of life in obsessive-compulsive disorder.

BACKGROUND: Obsessive compulsive disorder (OCD) is a chronic and disabling disorder. It profoundly compromises various aspects of patients' everyday life, thus affecting their quality of life (QoL). Using generic instruments, several studies have confirmed severely impaired health-related QoL in patients diagnosed with OCD. However, there has been a dearth of research on illness-specific QoL. AIMS: The present study aimed to further investigate subjective QoL in individuals with OCD with a focus on illness-specific aspects. METHOD: To assess subjective QoL in a broad OCD sample, an internet survey was conducted with 123 participants with obsessive-compulsive symptoms. The survey comprised both a generic (WHOQOL-BREF) and a novel self-developed OCD-specific QoL measure (QoLOC). Psychopathology was determined with diagnostic standard instruments (self-report forms of: Y-BOCS, OCI-R, BDI-SF). RESULTS: Regression analyses confirmed depression as the best predictor for decreased QoL. In addition, participants reported high despair resulting from OCD-related problems that differed across symptom subtypes. An exploratory factor analysis suggested four domains of OCD-specific problems tapped by the QoLOC: (1) depressiveness in association with OCD; (2) constraints in activities due to OCD symptoms or avoidance; (3) problems with partner and/or family due to OCD symptoms or avoidance; (4) self-concept/coping of own illness. CONCLUSIONS: Results produced a comprehensive picture of QoL impairments and their relation to psychopathology in a representative OCD sample. Illness-specific concerns should be further addressed in QoL research in OCD because such problems are not sufficiently mirrored in generic QoL measures.

Congruence and discrepancy between self-rated and clinician-rated symptom severity on the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) before and after a low-intensity intervention.

The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) is the most common measure of Obsessive-Compulsive symptom severity. The Y-BOCS interview is considered gold standard, but its self-rating format is increasingly used in clinical trials. Few studies investigated congruency and potential changes over treatment. This question is highly relevant, as a systematic bias might obscure results of clinical trials. We examined the relationship of self- and clinician-rated Y-BOCS scores in participants with obsessive-compulsive disorder in pre (N = 128), post, (4 weeks, n = 104) and follow-up (6 months, n = 98) assessments of a randomized-controlled clinical trial. We administered Y-BOCS interview via telephone paralleling online administration of the self-report form. Analyses showed medium-to-strong correlations of Y-BOCS interview and self-rating scores at pre-assessment. Patients rated symptoms lower than clinicians. Larger discrepancies were associated with hoarding and age. Congruency was inferior for obsessions relative to compulsions, largely owing to the "resistance against obsessions" item. Agreement strongly increased at post and follow-up. Though overall congruency between the two Y-BOCS forms was satisfactory, results suggest a "correction over time" effect. Such bias may distort the precise interpretation of treatment effects. Therefore, we made several suggestions to improve the reliability of change scores assessed with the Y-BOCS self-rating.

Obsessive-compulsive tendencies predict seeking proxies for understanding.

BACKGROUND AND OBJECTIVES: The Seeking Proxies for Internal States (SPIS) model of obsessive-compulsive disorder (OCD) postulates that obsessive-compulsive (OC) individuals have reduced access to their internal states and must therefore seek and rely on external proxies for these states. The present study extended this hypothesis to the feeling of understanding, which had not been examined previously in relation to OCD. METHODS: We presented 148 participants with a computerized task requiring them to read and understand a text on medieval architecture. Participants were randomly assigned to an ongoing feedback condition (comprehension quiz and answers provided after each text segment) or no-feedback condition (quiz and answers provided only at the end). Throughout, participants were offered proxies in the form of "learning aids," which were unrelated to text comprehension. Participants were divided to high vs. low OC tendencies based on a median split on a measure of OCD symptoms. RESULTS: As predicted, lacking feedback on understanding was associated with higher use of proxies and high OC participants used more proxies than low OC participants in the no-feedback condition. Actual understanding, as assessed by comprehension scores, was unrelated to OC tendencies. LIMITATIONS: Among other limitations discussed in the article, our results were obtained on a non-selected sample of students varying on OC tendencies. It would be important to replicate these findings with diagnosed OCD participants as compared to both non-clinical and anxiety disorders control participants. CONCLUSIONS: These findings extend the SPIS model to the domain of understanding and may have important clinical implications.

"Association splitting" versus cognitive remediation in obsessive-compulsive disorder: A randomized controlled trial.

Studies have confirmed the efficacy of the cognitive intervention Association Splitting (AS) in obsessive-compulsive disorder (OCD) when applied as a self-help technique. AS aims to alter symptom-provoking automated cognitive networks of OC-related stimuli by building new or strengthening established but weak neutral associations. The aim of this study was to investigate the acceptance and benefits of therapist-assisted AS as an add-on to cognitive behavioral therapy (CBT). One hundred and nine patients with OCD who were undergoing CBT were randomly assigned to either AS or cognitive remediation (CR). Both groups were assessed at baseline, 4 weeks and 6 months later. The primary measure was the Yale-Brown Obsessive Compulsive Scale. Although patients' acceptance of AS was good, AS was not better than CR regarding overall symptom severity. However, a larger decrease was found from baseline to 6 months follow-up in AS regarding avoidance. Moreover, subsidiary analyses excluding control patients who had obtained information about AS indicated its superiority. Because superiority of AS was found in post hoc analyses excluding control patients who had obtained information on AS, we suggest that contagion effects deserve consideration.

Patients' perspectives on treatment with Metacognitive Training for Depression (D-MCT): Results on acceptability.

BACKGROUND: Our understanding of how patients perceive and evaluate treatment for depression is scarce. Because dropout rates are high among individuals in treatment for depression, it is necessary to expand the focus of research to patients' perspectives on the treatment they receive. The aim of the two studies presented was to evaluate patient acceptance of Metacognitive Training for Depression (D-MCT), a highly standardized group intervention. METHODS: Acceptability was evaluated in an open case series (Study 1, N = 70) and a randomized controlled trial (RCT; Study 2, N = 84). In both studies, participants rated their subjective appraisal on a 15-item questionnaire after administration of eight D-MCT modules. In Study 1, a subsample of patients also evaluated modules individually after each session. In Study 2, ratings were compared to an active control intervention (walking and psychoeducation sessions), and assessment was repeated at 6-months follow-up. RESULTS: High rates of acceptance of the D-MCT were demonstrated in both studies immediately after treatment (post-assessment). In addition, the RCT showed better evaluations for the D-MCT than for the control condition at post-assessment as well as at 6-months follow-up. Weekly session evaluations in Study 1 indicated good acceptance for individual modules. LIMITATIONS: Evaluations could only be obtained from completers; blinding of patients and therapists was not possible. CONCLUSIONS: Results of the two studies suggest that D-MCT represents a promising group treatment in terms of patient acceptance and provide an example of how patients' feedback may be used to improve treatment.

Are we exaggerating neuropsychological impairment in depression? Reopening a closed chapter.

BACKGROUND: Meta-analyses conclude that individuals with depression display neurocognitive deficits. However, the extent to which some of these impairments occur due to secondary influences, and thus in part represent epiphenomena, has rarely been tested. Therefore, the authors examined the impact of performance motivation, attitude towards cognitive assessment, and momentary symptoms during assessment on neuropsychological test results in depression. RESEARCH DESIGN AND METHODS: Forty-five patients with depression and 60 nonclinical individuals underwent a comprehensive neuropsychological test battery. Before and after the assessment, each participant was asked to complete the Momentary Influences, Attitudes and Motivation Impact on Cognitive Performance Scale (MIAMI). RESULTS: As hypothesized, patients with depression performed worse than nonclinical controls on most neuropsychological parameters. Group differences achieved a medium effect size for parameters tapping speed and a large effect for parameters tapping accuracy. Yet, only one fourth of the patient population displayed abnormal scores (≥ 1 SD below the population mean). In line with the hypothesis, patients with depression were more fearful of test outcomes, complained more about negative momentary influences, and were less motivated (based on retrospective assessment) than controls, as assessed with the MIAMI. The MIAMI total score mediated the relationship between group status and test scores in three out of four analyses. When MIAMI scores were entered as covariate, group differences were largely reduced. DISCUSSION: Patients with depression show a more negative attitude towards testing, lower performance motivation, and more negative momentary influences, all of which induce malperformance. The results suggest that performance dysfunction does not necessarily mirror brain dysfunction in areas hosting cognitive functions but is confounded with other factors. Greater caution is warranted when interpreting the results of neuropsychological tests in depressed patients.

Further evidence for biased semantic networks in obsessive-compulsive disorder (OCD): when knives are no longer associated with buttering bread but only with stabbing people.

BACKGROUND AND OBJECTIVES: Semantic network models suggest that individuals with obsessive-compulsive disorder (OCD) process words with multiple meanings (e.g., "knife") more likely in an OC-related (i.e., "weapon") than in a neutral way (i.e., "cutlery"). Initial evidence was found in an online study. The aim of the current study was to investigate semantic networks in a clinical OCD sample and particularly to identify whether changes in semantic networks following the add-on intervention association splitting (AS) exceeded changes expected through cognitive behavioral therapy (CBT) alone. METHODS: An association task was presented to 36 healthy controls and 70 OCD patients over a period of eight weeks with OCD patients receiving CBT and an add-on intervention (randomized allocation to either AS or a computerized cognitive training). Participants were asked to generate up to five associations to standardized (OC-relevant, negative, neutral) and individual cue words. Associations were rated with regard to OC-relevance and valence. RESULTS: Analyses revealed that OCD participants produced a) significantly more OC-relevant associations and b) more negative associations than controls for cue words. In the OCD sample, the OC-relevance and valence of associations changed after therapy for personal cue words. This effect was associated with AS at statistical trend level. LIMITATIONS: No clinical control group was recruited; no inter-rater reliability was assessed for the association task. CONCLUSIONS: Further evidence for biased associative networks in OCD was found. Associations of individually chosen cue words proved to be modifiable by therapy.

Perceptual processing during trauma, priming and the development of intrusive memories.

BACKGROUND: Intrusive reexperiencing in posttraumatic stress disorder (PTSD) is commonly triggered by stimuli with perceptual similarity to those present during the trauma. Information processing theories suggest that perceptual processing during the trauma and enhanced perceptual priming contribute to the easy triggering of intrusive memories by these cues. METHODS: Healthy volunteers (N = 51) watched neutral and trauma picture stories on a computer screen. Neutral objects that were unrelated to the content of the stories briefly appeared in the interval between the pictures. Dissociation and data-driven processing (as indicators of perceptual processing) and state anxiety during the stories were assessed with self-report questionnaires. After filler tasks, participants completed a blurred object identification task to assess priming and a recognition memory task. Intrusive memories were assessed with telephone interviews 2 weeks and 3 months later. RESULTS: Neutral objects were more strongly primed if they occurred in the context of trauma stories than if they occurred during neutral stories, although the effect size was only moderate [Formula: see text] and only significant when trauma stories were presented first. Regardless of story order, enhanced perceptual priming predicted intrusive memories at 2-week follow-up (N = 51), but not at 3 months (n = 40). Data-driven processing, dissociation and anxiety increases during the trauma stories also predicted intrusive memories. Enhanced perceptual priming and data-driven processing were associated with lower verbal intelligence. LIMITATIONS: It is unclear to what extent these findings generalize to real-life traumatic events and whether they are specific to negative emotional events. CONCLUSIONS: The results provide some support for the role of perceptual processing and perceptual priming in reexperiencing symptoms.

Impact of emotionality on memory and meta-memory in schizophrenia using video sequences.

BACKGROUND AND OBJECTIVES: A vast amount of memory and meta-memory research in schizophrenia shows that these patients perform worse on memory accuracy and hold false information with strong conviction compared to healthy controls. So far, studies investigating these effects mainly used traditional static stimulus material like word lists or pictures. The question remains whether these memory and meta-memory effects are also present in (1) more near-life dynamic situations (i.e., using standardized videos) and (2) whether emotionality has an influence on memory and meta-memory deficits (i.e., response confidence) in schizophrenia compared to healthy controls. METHOD: Twenty-seven schizophrenia patients and 24 healthy controls were administered a newly developed emotional video paradigm with five videos differing in emotionality (positive, two negative, neutral, and delusional related). After each video, a recognition task required participants to make old-new discriminations along with confidence ratings, investigating memory accuracy and meta-memory deficits in more dynamic settings. RESULTS: For all but the positively valenced video, patients recognized fewer correct items compared to healthy controls, and did not differ with regard to the number of false memories for related items. In line with prior findings, schizophrenia patients showed more high-confident responses for misses and false memories for related items but displayed underconfidence for hits when compared to healthy controls, independent of emotionality. LIMITATIONS: Limited sample size and control group; combined valence and arousal indicator for emotionality; general psychopathology indicator. CONCLUSIONS: Emotionality differentially moderated memory accuracy, biases in schizophrenia patients compared to controls. Moreover, the meta-memory deficits identified in static paradigms also manifest in more dynamic settings near-life settings and seem to be independent of emotionality.

Attentional bias for affective visual stimuli in posttraumatic stress disorder and the role of depression.

An attentional bias for trauma-related verbal cues was frequently demonstrated in posttraumatic stress disorder (PTSD) using variants of the emotional Stroop task (EST). However, the mechanisms underlying the Stroop-effect are ill-defined and it is yet unclear how the findings apply to different paradigms and stimulus modalities. To address these open questions, for the first time a spatial-cuing task with pictorial cues of different emotional valence was administered to trauma-exposed individuals with and without PTSD, and non-trauma-exposed controls. Groups did not show different response profiles across affective conditions. However, a group effect was evident when comparing depressed with non-depressed individuals: Those with depression showed delayed attending towards trauma-related cues and faster attending away from negative cues. In correlational analyses, attentional avoidance was associated with both depression and PTSD symptom severity. These findings highlight the need for research on trauma populations and anxiety in general to pay closer attention to depression as an important confound in the study of emotional information processing.

A randomized controlled trial of internet-based therapy in depression.

Depression is among the most prevalent disorders worldwide. In view of numerous treatment barriers, internet-based interventions are increasingly adopted to "treat the untreated". The present trial (registered as NCT01401296) was conducted over the internet and aimed to assess the efficacy of an online self-help program for depression (Deprexis). In random order, participants with elevated depression symptoms received program access or were allocated to a wait-list control condition. After eight weeks, participants were invited to take part in an online re-assessment. To compensate for common problems of online studies, such as low completion rates and unclear diagnostic status, reminders and incentives were used, and clinical diagnoses were externally confirmed in a subgroup of 29% of participants. Relative to the wait-list group, program users experienced significant symptom decline on the Beck Depression Inventory (BDI; primary outcome), the Dysfunctional Attitudes Scale (DAS), the Quality of Life scale (WHOQOL-BREF) and the Rosenberg Self-Esteem Scale (RSE). Compared to wait-list participants, symptom decline was especially pronounced among those with moderate symptoms at baseline as well as those not currently consulting a therapist. Completion (82%) and re-test reliability of the instruments (r = .72-.87) were good. The results of this trial suggest that online treatment can be beneficial for people with depression, particularly for those with moderate symptoms.

Do it yourself? Self-help and online therapy for people with obsessive-compulsive disorder.

PURPOSE OF REVIEW: In spite of advances in the understanding and treatment of obsessive-compulsive disorder (OCD), for most patients some symptoms persist even after therapeutic intervention. Another large subgroup does not seek treatment at all, particularly due to shame or fear of stigma. The treatment gap in OCD is large and self-help is increasingly seen as a low-threshold form of intervention for individuals with minor symptoms or who are currently treatment-reluctant. Our review summarizes the expanding but still small literature on self-help and Internet interventions for OCD and provides advice on how to conduct (Internet) studies on self-help. Strategies to deal with methodological problems that notoriously plague Internet research are discussed. RECENT FINDINGS: Despite methodological limitations inherent in most studies considered for the current review, as well as the unreplicated nature of some of the more recent findings, self-help tools hold some promise. In particular, self-help interventions that are rooted in evidence-based concepts may be helpful as an add-on to standard interventions and as (initial) therapeutic strategies for those who are presently reluctant to participate in face-to-face treatment. SUMMARY: The current review identifies self-help, which is based on evidence-based concepts, as a promising clinical tool for the treatment of OCD. The current literature suggests that self-help can be a facilitator and aid to standard face-to-face interventions, rather than a rival.