Development of a Patient Adherence Scale for Exposure and Response Prevention Therapy

Exposure and response prevention (EX/RP) is an evidence-based treatment for obsessive-compulsive disorder (OCD). For EX/RP to be maximally effective, it is believed that patients must adhere outside of sessions to the procedures they learn in therapy. To date, there is no standard measure of patient EX/RP adherence, despite the importance of accurately assessing EX/RP adherence in both clinical research and practice. This paper describes the development of the Patient EX/RP Adherence Scale (PEAS), which assesses the patient's between-session adherence to the therapist's EX/RP instructions, and presents initial data on the scale's reliability and validity. The scale was designed to focus on the key procedures of EX/RP and to be brief enough to be used at each treatment session. The scale demonstrates excellent interrater reliability and good face and content validity. The usefulness of the scale is considered in the context of being an important tool to researchers trying to understand and improve outcomes of EX/RP for OCD as well as to EX/RP therapists in clinical practice. Future research will need to test the scale's reliability and validity in a larger sample of patients over the course of treatment.     

Measurement Error-Corrected Estimation of Clinically Significant Change Trajectories for Interventions Targeting Comorbid PTSD and Substance Use Disorders in OEF/OIF Veterans

In randomized control trials (RCTs), a focus on average differences between treatment arms often limits our understanding of whether individuals show clinically significant improvement or deterioration. The present study examined differences in individual-level clinical significance trajectories between Concurrent Treatment of PTSD and Substance Use Disorders Using Prolonged Exposure (COPE) and Relapse Prevention (RP). Eighty-one treatment-seeking veterans with a comorbid PTSD/SUD diagnosis were randomized to COPE or RP; data from an additional n = 48 patients who did not meet criteria for both disorders was used to establish a normative threshold. A newly developed, modernized approach to the Jacobson and Truax (1991) clinically significant change framework, using (a) moderated nonlinear factor analysis (MNLFA) scale scoring and (b) measurement error-corrected multilevel modeling (MEC-MLM) was used; this approach was compared to other approaches using conventional total scores and/or assuming no measurement error. Using a conventional approach to estimating the Reliable Change Index (RCI) yielded no differences between COPE and RP in the percentage of patients achieving statistically significant improvement (SSI; 88.9% for both groups). However, under MNLFA/MEC-MLM, higher percentages of patients receiving COPE (75.0%) achieved SSI compared to RP (40.7%). Findings suggest that, even though COPE and RP appear to reduce the same number of PTSD symptoms, MNLFA scoring of outcome measures gives greater weight to interventions that target and reduce “hallmark” PTSD symptoms.     

Semantic priming in Alzheimer's dementia: evidence for dissociation of automatic and attentional processes

The nature of the semantic memory deficit in dementia of the Alzheimer's type (DAT) was investigated in a semantic priming task which was designed to assess both automatic and attention-induced priming effects. Ten DAT patients and 10 age-matched control subjects completed a word naming semantic priming task in which both relatedness proportion (RP) and stimulus-onset asynchrony (SOA) were varied. A clear dissociation between automatic and attentional priming effects in both groups was demonstrated; however, the DAT subjects' pattern of priming deviated significantly from that of the normal controls. The DAT patients failed to produce any priming under conditions which encouraged automatic semantic processing and produced facilitation only when the RP was high. In addition, the DAT group produced hyperpriming, with significantly larger facilitation effects than the control group. These results suggest an impairment of automatic spreading activation in DAT and have implications for theories of semantic memory impairment in DAT as well as models of normal priming.     

Body size estimation in eating disorder patients: Testing the video distortion method on a life-size screen

The video distortion method on a life-size screen is a new method for studying eating disordered patients' estimations of their own body width. Testing this method in female patients (53 with anorexia nervosa, 38 with bulimia nervosa) and 36 normal females, yielded high to very high reliability scores (consistency and test-retest stability). A careful analysis of the ‘just noticeable difference’ showed that a 5% deviation from the undistorted image should be considered as within the range of accuracy. Taking this into account, anorectic patients appear to score below, above, as well as within the normal range. Bulimia nervosa patients are either accurate in their body estimations or overestimate their body width. All control Ss are correct in their estimations. With this method no significant differences were found between the anorectic patients and the controls. Bulimics differ significantly from anorectics and controls on their optative responses (i.e. what they wanted to look like) and their affective responses (i.e. what they felt they looked like).     

A measure for the assessment of eating disorders: reliability and validity studies of the Rating of Anorexia and Bulimia interview - revised version (RAB-R)

The Rating of Anorexia and Bulimia interview (RAB) is a Swedish semi-structured interview for clinical and research purposes for a wide range of eating disorder symptoms and related psychopathology. The objectives were to evaluate the reliability and validity of a revised RAB version (RAB-R). The RAB-R was assessed in terms of internal consistency, inter-rater and test-retest reliability, and criterion and convergent validity. Samples included a clinical sample of eating disorder patients (n = 71) and a sample of randomly drawn female controls (n = 31). The RAB-R showed satisfactory internal consistency, inter-rater and test-retest reliability, correlated well with related measures, and discriminated between patients and normal controls. We conclude that the RAB-R is a promising interview instrument and continued evaluation should focus on comparing subgroups of eating disorder patients with other clinical groups.     

Impaired face recognition does not preclude intact whole face perception

We studied intact and impaired processes in a prosopagnosic patient (RP). In Experiment 1, RP showed an inversion superiority effect with both faces and objects, with better performance when stimuli were presented upside down than in normal upright orientation. In Experiment 2, we studied the effect of face configuration directly by comparing matching performance with normal vs. scrambled faces. RP was worse with normal than with scrambled faces, whereas normal controls showed an advantage of a good face context. In Experiment 3, RP showed interference from external face features on the evaluation of internal face features. These results indicate, first, that although RP is impaired in face recognition and face matching, he does still encode the whole face rather than relying completely on parts-based procedures. Second, RP has a deficit at the level of the configural processes involved in finding subtle differences between individual faces, as his performance is worse when presented with a normal face configuration than with scrambled or inverted faces.     

Psychometric appraisal of the Scale for Interpersonal Behavior (SIB) in France.

The present study was carried out in France to evaluate the reliability and validity of the Scale for Interpersonal Behavior (SIB), a multidimensional measure of difficulty and distress in assertiveness that was originally developed in The Netherlands. This appraisal was conducted with a clinical sample (N = 166) and a general population sample (N = 150). The clinical series comprised 115 patients with social phobia and 51 patients with personality disorder, 28 of whom were of the avoidant type. Support was found for internal consistency and test-retest reliability of the French SIB. Compared to controls, both social phobics and patients with an avoidant personality disorder had significantly lower mean scores on all performance scales and significantly higher ones on all distress scales, with the social phobics occupying a position in between. Findings in relation to convergent and divergent validity were quite satisfactory. Sensitivity of the French SIB for detecting change was demonstrated in a subgroup of the clinical Ss who had undergone 15 sessions of cognitive-behavioral group therapy for underassertiveness.     

Arm adductor with arm abduction in rotator cuff tear patients vs. healthy--design of a new measuring instrument

The incidence of (a)symptomatic rotator cuff tears is high, but etiologic mechanisms are unclear and treatment outcomes vary. A practical tool providing objective outcome measures and insight into etiology and potential patient subgroups is desirable. Symptomatic cuff tears coincide with humerus cranialization. Adductor co-activation during active arm abduction has been reported to reduce subacromial narrowing and pain in cuff patients. We present an easy-to-use method to evaluate adductor co-activation. Twenty healthy controls and twenty full-thickness cuff tear patients exerted EMG-recorded isometric arm abduction and adduction tasks. Ab- and adductor EMG's were expressed using the "Activation Ratio (AR)" (-1 ≤ AR ≤ 1), where lower values express more co-activation. Mean control AR's ranged from .7 to .9 with moderate to good test-retest reliability (ICC: .60-.74). Patients showed significantly more adductor co-activation during abduction, with adductor AR's ranging between .3 (teres major) and .5 (latissimus dorsi). In conclusion, the introduced method discriminates symptomatic cuff tear patients from healthy controls, quantifies adductor co-activation in an interpretable measure, and provides the opportunity to study correlations between muscle activation and humerus cranialization in a straightforward manner. It has potential as an objective outcome measure, for distinguishing symptomatic from asymptomatic cuff tears and as a tool for surgical or therapeutic decision-making.     

The developmental profile: preliminary results on interrater reliability and construct validity

This study presents the preliminary results of research into the interrater reliability and construct validity of the Developmental Profile (DP). In the DP a number of developmental lines, such as Object-Relations, Self-Images, and Problem-Solving Capacities, are assessed and classified according to the level of functioning. A total of 108 profiles were assessed, drawn from three different categories of patients. The weighted kappa values for interrater reliability were sufficient. On the adaptive level, but also on the maladaptive levels Symbiosis and Resistance, significant differences were found between psychiatric patients, "normal controls" (dental patients) and somatic patients. No differences were recorded between the latter two groups. The conclusion is that the DP is a promising instrument, of which the reliability and validity has to be further investigated in order to contribute to scientific support for psychodynamic theory formation.     

Psychopathology scale of the Hutt adaptation of the Bender-Gestalt Test: reliability.

The test-retest reliability of the Hutt Adaptation of the Bender-Gestalt test was explored with a population of 40 process schizophrenics over a two-week interval. The total Psychopathology Scale Score was found to have high retest reliability for both male and female patients (rho = .87 for males and .83 for females). Moreover the three major components for the Scale were found to have high reliability, and fairly high reliabilities were obtained for patients scoring high as well as low on the Scale. Interjudge reliability was also found to be very high (rho = .895), confirming previous studies in this respect. On these grounds, the Scale offers promise both for clinical and research purposes.     

The Feasibility of Cognitive Screening of Patients with Ischaemic Stroke Using the Preliminary Neuropsychological Battery

In the present study, we assessed the reliability, validity and diagnostic accuracy of the non-verbal Preliminary Neuropsychological Battery (PNB) in a sample of stroke patients (n = 149) without significant aphasia and a sample of similarly aged healthy elderly controls (n = 122). The results indicate that as a brief bedside test of global cognitive function the PNB had satisfactory internal, external reliability and validity in this population and a cut-off point of ≤? 55 on the PNB had a sensitivity of 71% and specificity of 94% to detect significant cognitive impairments. Furthermore, better performance on the non-symbolic section of the PNB was associated improved with executive function. In common with other brief neuropsychological tests, the PNB was susceptible to ceiling, educational, functional capability and depression effects. The results here indicate that further research is needed to determine the utility of the PNB in a longitudinal cohort of aphasic and non-aphasic stroke survivors.     

Integrating Exposure and Response Prevention With a Mobile App to Treat Obsessive-Compulsive Disorder: Feasibility,Acceptability, and Preliminary Effects

Many individuals with obsessive-compulsive disorder (OCD) do not receive evidence-based care (specifically exposure and ritual prevention; EX/RP) due to barriers such as a lack of EX/RP-trained clinicians, geographic obstacles, and the cost and time associated with the treatment. Offering an integrated treatment model consisting of brief in-person therapy coupled with a mobile application (app) might be one way to increase access to and reduce the time burden (to clinicians and patients) of EX/RP. This pilot trial evaluated the feasibility, acceptability, and clinical effects of such a treatment program for adults with OCD. Thirty-three participants enrolled in the 8-week open trial. The integrated treatment program consisted of 3 to 5 in-person sessions followed by weekly phone calls supported by a mobile app (nOCD). Participants were evaluated by trained raters and completed self-report measures at baseline, midtreatment, posttreatment and 2-month follow-up; the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) was the primary outcome. This integrated treatment program was feasible and acceptable to participants. Of the 33 study entrants, 14 (42%) responded to treatment (Y-BOCS decrease ≥ 35% with CGI- of 1 or 2), and 8 (24%) achieved minimal symptoms (i.e., Y-BOCS ≤ 12). At 2-month follow-up (n = 20), 7/20 (35%) met criteria for treatment response, and 3/20 (15.0%) met criteria for treatment remission. Although preliminary, this model warrants further study as an efficacious and resource-efficient way to deliver EX/RP for some patients with OCD.     

The Swedish National Adult Reading Test (NART-SWE): a test of premorbid IQ

The purpose of this study was to construct a Swedish version of the National Adult Reading Test (NART-SWE), a test for assessment of premorbid IQ, and to investigate its validity and reliability on healthy controls and patients with mild Alzheimer's disease. As Swedish pronunciation rules are fixed, NART-SWE was constructed using loan words. NART-SWE has satisfactory psychometric properties: Inter-rater and retest reliability as well as internal consistency are very high. The NART-SWE demonstrates face validity. In addition, high correlation with IQ was obtained. A significant model emerged when using NART-SWE to predict IQ. Furthermore, no significant differences were observed when comparing performance for healthy controls' with that of patients with Alzheimer's disease on NART-SWE. It does appear that reading of irregular words is intact in mild Alzheimer's disease.     

Absolute and relative pitch: Global versus local processing of chords

Absolute pitch (AP) is the ability to identify or produce notes without any reference note. An ongoing debate exists regarding the benefits or disadvantages of AP in processing music. One of the main issues in this context is whether the categorical perception of pitch in AP possessors may interfere in processing tasks requiring relative pitch (RP). Previous studies, focusing mainly on melodic and interval perception, have obtained inconsistent results. The aim of the present study was to examine the effect of AP and RP separately, using isolated chords. Seventy-three musicians were categorized into four groups of high and low AP and RP, and were tested on two tasks: identifying chord types (Task 1), and identifying a single note within a chord (Task 2). A main effect of RP on Task 1 and an interaction between AP and RP in reaction times were found. On Task 2 main effects of AP and RP, and an interaction were found, with highest performance in participants with both high AP and RP. Results suggest that AP and RP should be regarded as two different abilities, and that AP may slow down reaction times for tasks requiring global processing.     

Adding motivational interviewing to exposure and ritual prevention for obsessive-compulsive disorder: an open pilot trial

Exposure and ritual prevention (EX/RP) is an efficacious treatment for obsessive-compulsive disorder (OCD), but high dropout rates and variable treatment adherence limit its effectiveness. Motivational interviewing (MI) has shown promise as an adjunct to symptom-focused treatments for improving treatment adherence and outcomes. The authors developed a manual integrating MI with EX/RP, consisting of three information-gathering/motivational enhancement sessions and 15 EX/RP sessions with an optional MI module to be used as needed. Six patients with moderate to severe OCD symptoms (Yale-Brown Obsessive Compulsive Scale [Y-BOCS] score> or =16) underwent treatment. Five showed a decrease in their baseline Y-BOCS scores and an increase in their quality of life, with three achieving an excellent response (i.e. Y-BOCS< or =12 at Session 18). The authors briefly describe the motivational strategies used in the six cases and suggest that integrating MI with standard EX/RP is a promising method to increase and sustain patient engagement with EX/RP. Challenges in combining these treatments and maintaining the integrity of each as well as limitations of the study are discussed.     

Women with diarrhoea-predominant irritable bowel syndrome show an increased pressure response to 35% carbon dioxide stress challenge

The responses to inhalation of 35% carbon dioxide (CO(2)) as a stressor were compared in female irritable bowel syndrome (IBS) patients and healthy controls to assess potential differences in cardiovascular, neuroendocrine and behavioural responses to stress. A total of 22 women (12 patients with ROME II defined diarrhoea-predominant IBS and 10 aged-matched controls) were challenged with a single vital capacity breath of 35% CO(2) (with 65% oxygen). Beat-to-beat blood pressure and heart rate were recorded prior to, during and after the inhalation. Serum cortisol concentration and behavioural ratings were measured pre- and post-inhalation. A typical pattern of responses to CO(2) was observed, characterised by a reduction in heart rate and increases in serum cortisol and anxiogenic symptoms; however, these responses did not differ between groups. Both groups also demonstrated an increase in systolic blood pressure; however, this response was significantly enhanced in IBS patients compared to healthy controls (P < 0.05). These findings demonstrate that females with diarrhoea-predominant IBS have an exaggerated pressor response to 35% CO(2) stress challenge, suggesting a more stress-responsive sympathetic nervous system.     

Long-term efficacy of exposure and ritual prevention therapy and serotonergic medications for obsessive-compulsive disorder

What is the long-term outcome of patients with obsessive-compulsive disorder (OCD) who are treated with exposure and response (ritual) prevention (EX/RP) alone, serotonergic medications alone, or their combination? How is the long-term outcome of these patients affected by the discontinuation? Follow-up assessments were conducted with 62 patients treated for OCD an average of 17 months posttreatment (range: 6-43 months). Patients received one of three treatments: serotonergic medications (fluvoxamine or clomipramine), intensive behavior therapy involving EX/RP, or intensive EX/RP with concurrent antidepressant medication. At follow-up, no differences in OCD symptom severity were found among the three treatment groups. However, when current medication use was taken into consideration, differences among the three treatment groups emerged. Among patients who were medication-free at the time of follow-up assessment (n=37), those in the EX/RP-alone and EX/RP-with-medication groups had lower symptom severity ratings than those in the medication-only group on 4 out of 6 measures. There were no differences in OCD severity ratings among patients taking medications at follow-up (n=25). Although these findings are interpreted with caution due to the uncontrolled nature of the study, results suggested that long-term outcome may be superior following EX/RP than following serotonergic medications, after discontinuation. For patients who remain on medications, the treatment produced benefits equivalent to EX/RP.     

Motivation-Hygiene Aspects of Vocational Indecision and College Achievement

Subjective and objective scales designed to assess Herzberg and Hamlin's (1961) motivation and hygiene constructs were given to 133 male university freshmen. On the basis of ACT scores and responses to a university admission form, they were classified into groups having no vocational preferences (NP), non-realistic preferences (NRP), and realistic preferences (RP). NRP and RP groups were more motivation oriented than NP group, and on one scale NRP group was more hygiene oriented than RP group. A group of 34 male clients was more motivation oriented than NP group. With ACT scores partialled out, grade-point average was correlated positively with endorsement of certain “motivator” job incentives and negatively with endorsement of some “hygiene” incentives. The findings and theory are suggested as relevant to vocational and educational counseling.     

A REVIEW OF ACADEMIC PERMANENT-PRODUCT DATA COLLECTION AND RELIABILITY PROCEDURES IN APPLIED BEHAVIOR ANALYSIS RESEARCH1

Three publication sources were reviewed to determine the recent conventions for collecting, and assessing the reliability of, academic permanent-product data (handwriting, examination papers, etc in applied behavior analysis. The primary source was the Journal of Applied Behavior Analysis (1968–1974). Secondary sources included conference proceedings titled, A new direction in education: behavior analysis (E. Ramp and B. L. Hopkins, Eds., Lawrence, Kansas: Support and Development Center for Follow Through, Department of Human Development, University of Kansas, 1971), and Behavior Analysis and Education (G. Semb, Ed., Lawrence, Kansas: Support and Development Center for Follow Through, Department of Human Development, University of Kansas, 1972). Finally, as a test of the generality of the findings in the two applied behavior analysis sources, the current issue of each of 14 psychological and/or educational journals was reviewed. Thirty JABA studies reported academic permanent-product data, but only 14 reported reliability. Increasingly more product data through 1973 have been reported along with a greater proportion of authors reporting reliability. The review of the two conference proceeding publications revealed the same trend. In 1971, only three studies reported academic product data, none with reliability, while in 1972, 15 reported academic data, nine including reliability assessment. The review of 14 current education/psychology journal issues revealed four studies reporting academic data, none with reliability. Across all sources, about one-half of the studies reported reliability. Most of the studies reporting reliability described the frequency of reliability assessment, with approximately equal numbers of JABA studies reporting reliability for each paper or reliability for each session. The use of uninformed observers was reported in only three JABA studies and one conference study. Marks made on subjects' papers by either the teacher or the primary observer were reported masked for reliability purposes by only two JABA and two conference studies. Reliability was calculated on a session total basis in two JABA studies. Point-by-point agreement was given in nine JABA and three conference studies. Perfect reliability (mean agreement of 100%) was reported in only six JABA and three conference studies. Scores between 90 and 100% were reported in nine JABA and four conference studies. Scores below 80% were reported in three JABA studies. No other percentage agreement scores were reported, although one JABA study reported correlational reliability (Pearson r). In summary, recently more studies have dealt with academic data and, until 1974, a greater proportion of these studies reported reliability assessment, and relatively few studies reported either replicable methods, 100% agreement, or controls for maintaining rater independence.     

The claustrophobia scale: a psychometric evaluation

This article presents a psychometric evaluation of the Claustrophobia Scale (CS), consisting of one subscale for measuring anxiety (20 items, 0-4) and one for avoidance (18 items, 0-2). Participants were 87 claustrophobic patients and 200 normal controls randomly selected from the community. The results show that CS has excellent internal consistency, high test-retest reliability, concurrent and discriminant validity. The patients and controls differ significantly on the total scores of anxiety and avoidance, as well as on each individual item scores. The CS was also found to be sensitive to change after cognitive behavioral treatment. Preliminary factor analyses yielded two factors for each subscale; "Being in small enclosed spaces" and "Other people present", accounting for large proportions of the variance. The CS is useful both as a state, and as an outcome self-report measure of claustrophobia.