Subtypes of obsessive-compulsive disorder: Implications for specialized cognitive behavior therapy

Although obsessive-compulsive disorder (OCD) is a heterogeneous condition, OCD subtypes have received limited attention in trials of cognitive behavior therapy (CBT). Because many patients with OCD do not respond optimally to CBT, it is important for clinicians to consider whether variability in treatment response is related to symptom presentation. Treatment modifications for patients without overt compulsions or with hoarding symptoms show promise. In this article we discuss the available research addressing the treatment of OCD subtypes, review the clinical characteristics and treatment recommendations for prominent OCD subtypes, raise the prospect of using dysfunctional beliefs as a potentially helpful conceptual approach to subtyping OCD and matching treatment to subtypes, and consider future directions in the treatment of OCD subtypes.     

Special series Subtypes of obsessive-compulsive disorder: Introduction

An accumulating body of research suggests that obsessive-compulsive disorder (OCD) is a heterogeneous condition, yet there is not yet a consensus on how best to conceptualize subtypes or dimensions of the disorder. This special series considers theoretical and practical issues pertaining to OCD subtypes. New possibilities for conceptualizing differences among OCD patients are considered, and avenues for treating different presentations of obsessions and compulsions are discussed. Treatment programs continue to be refined and outcome studies continue to demonstrate that tailoring cognitive-behavioral treatment toward specific presentations of OCD (e.g., contamination fears, severe obsessions) represents the future of OCD treatment. The articles in this special series are intended to further efforts to consider ways of better understanding the heterogeneity of OCD.     

Investigating Treatment Outcomes Across OCD Symptom Dimensions in a Clinical Sample of OCD Patients

Despite the heterogeneous nature of obsessive-compulsive disorder (OCD), many self-report assessments do not adequately capture the clinical picture presenting within each symptom dimension, particularly unacceptable thoughts (UTs). In addition, obsessions and ordering/arranging compulsions are often underrepresented in samples of treatment outcome studies for OCD. Such methodological discrepancies may obscure research findings comparing treatment outcomes across OCD symptom dimensions. This study aimed to improve upon previous research by investigating treatment outcomes across OCD symptom dimensions using the Dimensional Obsessive-Compulsive Scale, which offers a more comprehensive assessment of UTs. The study included a primarily residential sample of 134 OCD patients. Results indicated that there were no significant differences in treatment outcomes across symptom dimensions. However, the severity of UTs remained significantly greater than other symptom dimensions at both admission and discharge. Thus, it is possible that UTs may exhibit uniquely impairing features, compared with other symptom dimensions. It is also possible that these findings may reflect the characteristics of the residential OCD samples. These speculations as well as implications for OCD treatment and future research are discussed.     

Anxiety sensitivity and obsessive--compulsive disorder

Anxiety sensitivity (AS), a cognitive risk factor for anxiety disorders, was evaluated in a homogeneous obsessive-compulsive disorder (OCD) sample. A total of 280 individuals with OCD completed measures. Evaluation of the Anxiety Sensitivity Index revealed a latent structure that was congruent with previous studies showing a single higher order and three lower order factors, although greater variance was accounted for by the general factor than in a previous study. AS was significantly associated with OCD symptom severity after controlling for other putative cognitive risk factors, although the additional variance explained was small. Variability in the relationship of AS to OCD symptom severity was found across OCD symptom subgroups. Results suggest that AS might be an important aspect of OCD-relevant cognition for specific OCD subgroups, and the need for experimental evaluation is discussed.     

Subtyping obsessive-compulsive disorder: A taxometric analysis

Obsessive-compulsive disorder (OCD) is a heterogeneous condition comprising multiple symptoms. Researchers have identified OCD subtypes using a range of symptom-based research methods, including factor and cluster analyses and examination of differential treatment response. These methods can be challenged on the grounds that they fail to demonstrate the existence of discrete taxonomic entities. Furthermore, no study has examined subtyping on the basis of cognitive characteristics. In the present study, the categorical vs. dimensional status of 6 possible subtypes of OCD was examined using taxometric methods. Three potential cognitive subtypes (based on high levels of responsibility/threat estimation, perfectionism/certainty, and importance/control of thoughts) and 3 potential symptomatic subtypes (based on elevated levels of contamination obsessions and cleaning compulsions, checking, and obsessionality) were examined using the MAXEIG and MAMBAC procedures in a sample of 404 diagnosed cases of OCD. Findings favored dimensional models of the potential responsibility, perfectionism, checking, and contamination subtypes, but offered qualified support for taxonic models of the importance/control of thoughts and obsessional subtypes. Implications for the subclassification of OCD are discussed.     

The role of cognitions in OCD treatment: toward rapprochement

The authors of the papers in this special issue have underscored the efficacy of both psychological and pharmacological treatments for OCD. Despite the potency of these interventions, complete symptom remission rarely occurs. Furthermore, problems related to treatment drop-out, the persistence of residual symptoms despite adequate therapy, patients' vulnerability to relapse and recurrence, and the lack of a clear method for managing co-morbidity or treating OCD subtypes remain incompletely addressed. This response to the authors' papers evaluates their positions and extends their papers by examining issues such as how cognitive therapy and exposure and response prevention can best be integrated, the role of medication in OCD treatment, factors that impact treatment readiness and/or resistance, and the need for effectiveness research.     

Patterns of neural response to emotive stimuli distinguish the different symptom dimensions of obsessive-compulsive disorder

Despite its heterogeneous symptomatology, obsessive-compulsive disorder (OCD) is currently conceptualized as a unitary diagnostic entity. Recent factor-analytic studies have identified several OCD symptom dimensions that are associated with different demographic variables, comorbidity, patterns of genetic transmission, and treatment response. Functional abnormalities in neural systems important for emotion perception, including the orbitofrontal cortex, lateral prefrontal cortex, anterior cingulate gyrus, and limbic regions, have been reported in OCD. In this review, we discuss the extent to which neurobiological markers may distinguish these different symptom dimensions and whether specific symptom dimensions, such as contamination/washing, are associated with abnormalities in emotion and, in particular, disgust, perception in OCD. Also discussed are findings that indicate that anxiety can be induced in healthy volunteers in response to OCD symptom-related material, and that associated increases in activity within neural systems important for emotion perception occur to washing- and hoarding-related material in particular in these subjects. Further examination of neural responses during provocation of different symptom dimensions in OCD patients will help determine the extent to which specific abnormalities in neural systems underlying emotion perception are associated with different symptom dimensions and predict treatment response in OCD.     

The Role of Cognitions in OCD Treatment: Toward Rapprochement

The authors of the papers in this special issue have underscored the efficacy of both psychological and pharmacological treatments for OCD. Despite the potency of these interventions, complete symptom remission rarely occurs. Furthermore, problems related to treatment drop‐out, the persistence of residual symptoms despite adequate therapy, patients' vulnerability to relapse and recurrence, and the lack of a clear method for managing co‐morbidity or treating OCD subtypes remain incompletely addressed. This response to the authors' papers evaluates their positions and extends their papers by examining issues such as how cognitive therapy and exposure and response prevention can best be integrated, the role of medication in OCD treatment, factors that impact treatment readiness and/or resistance, and the need for effectiveness research.     

Cognitive deficits of executive functions and decision‐making in obsessive‐compulsive disorder

The nature of cognitive deficits in obsessive‐compulsive disorder (OCD) is characterized by contradictory findings in terms of specific neuropsychological deficits. Selective impairments have been suggested to involve visuospatial memory, set shifting, decision‐making and response inhibition. The aim of this study was to investigate cognitive deficits in decision‐making and executive functioning in OCD. It was hypothesized that the OCD patients would be less accurate in their responses compared to the healthy controls in rational decision‐making on a version of the Cambridge gambling task (CGT) and on the color‐word interference test and on a version of the Tower of Hanoi test (tower test) of executive functioning. Thirteen participants with OCD were compared to a group of healthy controls (n = 13) matched for age, gender, education and verbal IQ. Results revealed significant differences between the OCD group and the healthy control group on quality of decision‐making on the CGT and for achievement score on the tower test. On these two tasks the OCD group performed worse than the healthy control group. The symptom‐dimension analysis revealed performance differences where safety checking patients were impaired on the tower test compared to contamination patients. Results are discussed in the framework of cognition and emotion processing and findings implicate that OCD models should address, specifically, the interaction between cognition and emotion. Here the emotional disruption hypothesis is forwarded to account for the dysfunctional behaviors in OCD. Further implications regarding methodological and inhibitory factors affecting cognitive information processing are highlighted.     

Obsessive beliefs predict cognitive behavior therapy outcome for obsessive compulsive disorder

Cognitive accounts of obsessive compulsive disorder (OCD) assert that core beliefs are crucial to the development, maintenance, and treatment of the disorder. There are a number of obsessive beliefs that are considered fundamental to OCD, including personal responsibility, threat estimation, perfectionism, need for certainty, importance of thoughts, and thought control. The present study investigated if pretreatment severity of obsessive beliefs, as well as the change in obsessive beliefs following treatment, predicted intensive, residential cognitive behavioral therapy (CBT) treatment outcome. A series of hierarchical regression analyses were carried out to investigate the relations between obsessive beliefs and treatment outcome. Results indicated that inflated pretreatment responsibility/threat estimation beliefs were significantly related to less overall obsessive compulsive (OC) symptom reduction at discharge, explaining 2% of the overall variance. Changes in obsessive beliefs broadly, and importance/control of thoughts specifically, were positively related to overall OC symptom reduction at discharge, respectively explaining 18% and 3.6% variance. Results are modestly consistent with a number of theoretical models, which argue that inflated responsibility, threat estimation, and thought control are important to the maintenance and treatment of OCD.     

Incompleteness and Disgust Predict Treatment Outcome in Pediatric Obsessive-Compulsive Disorder

Increasing evidence suggests that pediatric obsessive-compulsive disorder (OCD) is motivated not only by fear but also by feelings of incompleteness and disgust. However, it is currently unclear whether emotion involvement in OCD symptoms is associated with treatment response in youth with OCD. The present study examined whether treatment outcome for youth with OCD was predicted by the degree to which fear, disgust, and incompleteness were involved in baseline OCD symptoms. Children and adolescents with OCD entering treatment for this condition (N = 111) were administered standardized OCD symptom measures and an interview designed to assess the degree of fear, incompleteness, and disgust experienced during current OCD symptoms. Follow-up assessments occurred on average 13 months after baseline with each participant coded for outcome according to internationally acknowledged change criteria for pediatric OCD. Higher levels of incompleteness and disgust as part of baseline OCD symptoms predicted poorer outcome. The degree of fear during baseline OCD symptoms did not predict outcome. If replicated under controlled conditions, these results suggest that incompleteness and disgust may act as barriers to improvement in pediatric OCD and that treatment modifications that target these emotion-related motivators may improve outcome for a subset of youth.     

Irritability in Children and Adolescents With OCD

Irritability is a common, impairing transdiagnostic symptom in childhood psychopathology, though it has not been comprehensively studied in pediatric obsessive-compulsive disorder (OCD). Further, the central cognitive behavioral treatment component for OCD, exposure and response prevention therapy (ERP), has been recently proposed as a treatment for irritability. This study aimed to evaluate whether certain clinical characteristics are associated with irritability in pediatric OCD and whether irritability reduces following ERP. Participants were 161 youth (ages 7–17) with OCD and a caregiver participating in a randomized controlled trial of D-cycloserine or pill placebo augmented ERP. Participants completed validated assessments during treatment. Irritability was significantly and positively associated with depressive symptoms, defiance, functional impairment, and family accommodation, but was not associated with pretreatment OCD severity, symptom dimensions, obsessive beliefs. Irritability significantly declined following treatment, with over half of youth with any pretreatment irritability experiencing clinically significant change, though this change was not related to OCD improvement. Results suggest that irritability may be a marker of psychiatric comorbidity, parental accommodation, and impairment in youth with OCD. Implications for the exposure-based treatment of irritability are discussed.     

An investigation of traumatic life events and obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD), like most other psychiatric disorders, is suspected of being influenced by an interaction between life events and genes, both with regard to onset and course of illness. To date, no specific genes have been identified as playing a frequent role, and only a relatively few empirical studies have assessed the association between stressful life events (SLEs) and OCD. The present study builds on past research by examining the potential contributions from traumatic life events (TLEs) on the severity and symptom features in 265 individuals with Structured Clinical Interview for DSM-IV (SCID)-diagnosed OCD. Of these participants 54% endorsed having experienced at least one TLE in their life time. The presence of one or more TLEs was associated with increased OCD symptom severity. This relationship remained significant despite controlling for key variables including age, OCD age-of-onset, comorbidity, and depressive symptoms. In addition, obsessions/checking and symmetry/ordering were two of four symptom factors that were specifically associated with the occurrence of TLEs. These results are generally supportive of a pathoplastic relationship between TLEs and OCD symptomatology and thus suggest the need for greater systematic consideration of life stresses in research focused on the nature and treatment of OCD.     

Changes in quality of life following cognitive-behavioral therapy for obsessive-compulsive disorder

Cognitive-behavioral therapy (CBT) incorporating exposure and response prevention is a first line treatment for obsessive-compulsive disorder (OCD). Although, the efficacy of CBT in reducing OCD symptoms is well documented, less is known about its effects on quality of life (QOL). In the current study, functional impairment aspects of QOL (as measured by the Sheehan Disability Scale) were assessed among 70 adult outpatients with OCD before and after CBT. Statistically significant improvements in QOL and large pre- to post-treatment effect sizes were observed for work, social, and family functioning. Improvements in social and family functioning were predicted by improvements in OCD symptom severity even after controlling for improvements in depressive symptoms. In addition, clinically significant change in OCD symptoms and QOL were highly related, although there was a subset of participants whose symptoms improved without corresponding improvements in QOL. These results suggest that the effects of CBT may extend beyond OCD symptom reduction to QOL.     

Multimedia Field Test: Can Users Strike Out OCD With the NOCD App?

NOCD is a mobile application that was developed as an adjunct to evidence-based treatment for individuals diagnosed with OCD. NOCD is not a stand-alone treatment, but rather a resource for patients to access supported strategies outside of treatment sessions. NOCD allows users to assess OCD symptom severity, create exposure and response prevention treatment plans, participate in planned weekly out-of-session exposure exercises, receive guidance during unexpected OCD episodes, share assessment and treatment data, as well as communicate with other NOCD users in an online community. Despite some challenges with initial set-up and inflexibility with varying OCD presentations, we believe this application has strong potential to enhance treatment for patients with OCD. At present, NOCD has not been adequately evaluated in a controlled manner. Although quite promising, research is now needed to examine the extent to which NOCD indeed improves engagement and clinical outcomes relative to traditional evidence-based treatment options.     

Development and Validation of a Child Version of the Obsessive Compulsive Inventory

Surprisingly, only 3 self-report measures that directly assess pediatric obsessive-compulsive disorder (OCD) have been developed. In addition, these scales have typically been developed in small samples and fail to provide a quick assessment of symptoms across multiple domains. Therefore, the current paper presents initial psychometric data for a quick assessment of pediatric OCD across multiple symptom domains, a child version of the Obsessive Compulsive Inventory (the OCI-CV). Data from a sample of over 100 youth ages 7 to 17 with a primary DSM-IV diagnosis of OCD support the use of the 21-item OCI-CV. Results support the use of the OCI-CV as a general index of OCD symptom severity and in 6 symptom domains parallel to those assessed by the revised adult version of the scale (OCI-R). The OCI-CV showed strong retest reliability after approximately 1.5 weeks in a subsample of 64 participants and was significantly correlated with clinician-rated OCD symptom severity and parent and child reports of dysfunction related to OCD. Significantly stronger correlations with self-reported anxiety than with depressive symptoms provide initial support for the divergent validity of the measure. Finally, preliminary data with 88 treatment completers suggest that the OCI-CV is sensitive to change.     

The Application of Acceptance and Commitment Therapy to Obsessive-Compulsive Disorder

This paper is part of a case series illustrating the application of different therapies to a case of obsessive-compulsive disorder (OCD). It describes the hypothetical application of Acceptance and Commitment Therapy (ACT). This paper covers the philosophy and basic research on language and cognition that inform ACT. It also provides an ACT-based case conceptualization of this case and examples of therapeutic procedures. The goal of this paper is to familiarize clinicians with the use of ACT for OCD.     

The Shifting Subtypes of ADHD: Classification Depends on How Symptom Reports are Combined

Research on the correlates of ADHD subtypes has yielded inconsistent findings, perhaps because the procedures used to define subtypes vary across studies. We examined this possibility by investigating whether the ADHD subtype distribution in a community sample was sensitive to different methods for combining informant data. We conducted a study to screen all children in grades 1-5 (N = 7847) in a North Carolina County for ADHD. Teachers completed a DSM-IV behavior rating scale and parents completed a structured telephone interview. We found substantial differences in the distribution of ADHD subtypes depending on whether one or both sources were used to define the subtypes. When parent and teacher data were combined, the procedures used substantially influenced subtype distribution. We conclude the ADHD subtype distribution is sensitive to how symptom information is combined and that standardization of the subtyping process is required to advance our understanding of the correlates of different ADHD subtypes.