强迫症病理的认知–行为研究述评

认知–行为领域对强迫症(OCD)的病理进行了深入的探索。强迫症的认知–行为理论认为功能失调性信念、应对策略及中和行为对强迫症的发生和维持有重要作用; 强迫症的安全动机模型把强迫行为归因于安全动机系统不能产生停止安全防卫行为的信号, 在此基础上有研究表明, 在做停止强迫行为的决策时, 强迫症患者依赖于主观停止标准, 导致决策困难, 延长了强迫行为持续的时间。通过整理近年来此领域的研究, 认为趋–避冲突存在于一些强迫症患者中, 且可能是导致强迫症的又一重要因素。     

Cognitive-Behavioral Treatment of Generalized Anxiety Disorder

Generalized Anxiety Disorder (GAD) can be treated effectively with cognitive-behavioral therapy. When working with clients who have GAD, therapy can focus on four central areas that help to promote therapeutic change. The initial focus of therapy is on developing a sound therapeutic alliance and educating the client about anxiety symptoms. Skills training focuses on relaxation training and cognitive changes that can help clients confront their worries in a constructive manner. Then, exposure to internal and external aspects of the anxiety can help clients test and refine their coping skills. Finally, because of the chronic nature of GAD, relapse prevention strategies can be used to help maintain treatment gains over time. These strategies allow a broad but flexible treatment plan that can be adapted to the unique needs of each individual client.     

Intensive Family-Based Cognitive-Behavioral Therapy for Pediatric Obsessive-Compulsive Disorder: Applications for Treatment of Medication Partial- or Nonresponders

Serotonin reuptake inhibitor medications and cognitive-behavioral therapy (CBT) are both effective treatments for pediatric obsessive-compulsive disorder (OCD). Despite recommendations that youth with OCD be treated with CBT alone or together with serotonin reuptake inhibitor medication, many youth are treated with medication alone or with non-CBT psychotherapy initially. Although effective, symptom remission with medication alone is rare (e.g., only 21.4% of youth achieved remission with sertraline in the Pediatric OCD Treatment Study, 2004) and residual symptoms often remain (e.g., 58% of subjects in the March et al. [1998] sertraline trial were not considered treatment responders). This paper reviews the literature on the efficacy of CBT for pediatric OCD, particularly as it relates to the treatment of youth with prior inadequate response to medication. It also describes an intensive, family-based CBT program for children and adolescents with OCD and support for its efficacy among those with prior partial- or nonresponse to medication. Finally, we present a case study of an adolescent girl with OCD who participated in the intensive treatment program after having limited benefit from medication and non-CBT psychotherapy and experienced a favorable response.     

Characteristics of Individuals Seeking Treatment for Obsessive-Compulsive Disorder

Despite severe functional impairment, only 35% to 40% of individuals with obsessive-compulsive disorder (OCD) seek treatment, and fewer than 10% receive evidence-based treatment. The current study examined the characteristics of 525 individuals who contacted the clinic of the Center for the Treatment and Study of Anxiety at the University of Pennsylvania to inquire about OCD treatment and completed a phone screen. Callers who were deemed appropriate for the clinic (n = 396, 75%) were invited to participate in an in-person intake evaluation. Only 137 (35%) of the eligible individuals completed the intake evaluation (“treatment intake group”) whereas the majority (n = 259, 65%) did not (“phone screen–only group”). Compared to individuals in the phone screen–only group, those in the treatment intake group were younger, less likely to endorse depressed mood, and more likely to have received a diagnosis of OCD, to have previously sought psychological services, and to have taken psychotropic medication. The findings suggest that familiarity with their diagnosis and past contact with mental health professionals enhance openness to explore yet another treatment. In contrast, lack of awareness about the problem and depressed mood may reduce openness to seek treatment.     

An Integrative Brief Treatment Approach for Obsessive-Compulsive Disorder

This article reports on the integrated application of cognitive therapy, transactional analysis techniques, and the behavioral technique of response prevention using self-instructional training and behavioral substitution in a brief therapy approach. These methods were applied in the case of a young man who presented with compulsions to perform repetitive and ordering rituals with the belief that it would prevent his girlfriend from becoming pregnant. A 21-year-old white male who had performed 3 to 5 hours of rituals daily for several years was able to eliminate the majority of his compulsive behaviors and reduce his level of anxiety after eight clinical therapy sessions. Results were maintained at 6-month follow-up. The clear precipitating factors and the unusual maintaining variables for the disorder in the client are described. The author discusses the case in light of current theoretical, therapeutic, and biomedical understandings of the disorder.     

Acceptability,Feasibility, and Effectiveness of Internet-Based Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder in New York

Cognitive-behavioral therapy (CBT), consisting of exposure and response prevention (EX/RP), is both efficacious and preferred by patients with obsessive–compulsive disorder (OCD), yet few receive this treatment in practice. This study describes the implementation of an Internet-based CBT program (ICBT) developed in Sweden in individuals seeking OCD treatment in New York. After translating and adapting the Swedish ICBT for OCD, we conducted an open trial with 40 adults with OCD. Using the RE-AIM implementation science framework, we assessed the acceptability, feasibility, and effectiveness of ICBT. The Yale–Brown Obsessive Compulsive Scale (Y-BOCS) was the primary outcome measure. Of 40 enrolled, 28 participants completed the 10-week ICBT. In the intent-to-treat sample (N = 40), Y-BOCS scores decreased significantly over time (F = 28.12, df = 2, 49, p < . 001). Depressive severity (F = 5.87, df = 2, 48, p < . 001), and quality of life (F = 12.34, df = 2, 48, p < . 001) also improved. Sensitivity analyses among treatment completers (N = 28) confirmed the intent-to-treat results, with a large effect size for Y-BOCS change (Cohen’s d = 1.38). ICBT took less time to implement than face-to face EX/RP and participants were very to mostly satisfied with ICBT. On a par with results in Sweden, the adapted ICBT program reduced OCD and depressive symptoms and improved quality of life among individuals with moderate to severe OCD. Given its acceptability and feasibility, ICBT deserves further study as a way to increase access to CBT for OCD in the United States.     

Cognitive-Behavioral Treatment of Panic Disorder: Confronting Situational Precipitants

Panic Disorder is a common, debilitating psychological problem which is often effectively treated through cognitive behavioral approaches. Cognitive-behavioral treatment incorporates education, relaxation training, cognitive therapy, behavioral exposure, and relapse prevention treatment strategies. A case illustration demonstrates how cognitive-behavioral treatment facilitated a client's ability to identify and confront situational precipitants to panic in a gradual and systematic manner. A therapeutic and collaborative relationship provided the foundation for treatment, while education helped the client to understand the vicious cycle between somatic symptoms, catastrophic thoughts, and anxiety. Passive relaxation training incorporated deep breathing, muscle relaxation, and positive imagery generated from the client's own experience. Cognitive restructuring involved identifying automatic thoughts related to panic, challenging dysfunctional beliefs associated with the client's depression and low self-esteem, and generating alternative ways of thinking. Behavioral exposure (e.g., imaginal exposure, behavioral rehearsal, in vivo techniques) helped the client gain a greater sense of mastery over panic attacks triggered by his fear of hypodermic needles. Over the course of treatment, the frequency and intensity of the client's panic attacks decreased. Furthermore, the client's sense of mastery over panic had beneficial effects on his mood and self-esteem. Treatment gains were maintained at one-year follow-up.     

Effects of Group Functional Behavior-Based Cognitive-Behavioral Therapy for Obsessive-Compulsive Behavior in a Youth With Autism Spectrum Disorder

Individuals with Autism Spectrum Disorder (ASD) often present with comorbid Obsessive Compulsive Behaviors (OCBs), but little research exists on effective intervention for OCBs. Using a single-case experimental design, this study highlights the efficacy of a Group Functional Behavior-based Cognitive-Behavior Therapy (Fb-CBT) to reduce OCBs in an 11-year-old youth with ASD. Tailored to the individual needs of this youth, Fb-CBT included traditional CBT components (e.g., psychoeducation, cognitive-behavioral skills training, and exposure and response prevention) coupled with functional behavior assessment and intervention. Time-series parent report data and standardized measures showed clinically significant decreases in OCBs, an increase in psychosocial functioning, and high consumer satisfaction.     

强迫症的元认知研究:进展与趋势

该文分析了强迫症患者在现实监控、知道感、元认知信念和责任控制等方面的研究,发现缺乏对不同类型强迫症元认知差异的研究、被试选取的典型性和代表型有待提高,现实监控障碍的身心原因尚不明确、责任-控制障碍形成的机制研究不足.指出元认知干预的强迫症治疗范式、强迫症与其他精神症元认知障碍的比较、强迫症元认知的认知神经科学探索和强迫性网络使用的元认知机制等是未来研究的趋势.     

Successful and Unsuccessful Treatment of Obsessive-Compulsive Disorder in Older Adults

Obsessive compulsive disorder (OCD) is a condition that was once thought to rarely occur in older adults. Subsequently, treatment of OCD in the elderly has received very limited attention. However, recent epidemiological studies have highlighted the prevalence of this disorder in late life and, thus, focus has turned to comprehensive treatment for this population. This article describes two older adults who received intensive, cognitive behavioral treatment in an inpatient setting. Treatment modifications incorporating age-specific concerns are discussed, as are potential factors influencing treatment success versus symptom relapse.     

A Case of Obsessive-Compulsive Disorder

This article presents the case of a 51-year old woman with obsessive-compulsive disorder. “Caroline” reported obsessions of harming people secondary to spreading her “bad energy,” which is experienced as dust on her hands and in her mouth. To prevent harm coming to others she mentally “vacuums” the dust, creates mental protective barriers around nearby people and avoids touching others for fear of transmitting her bad energy. Although she reported a childhood onset of obsessions and compulsions, it exacerbated in the context of multiple stressors 4 years prior to seeking treatment. Her Yale-Brown Obsessive Compulsive Scale total score was in the moderate range at intake. Predisposing, precipitating, and maintaining factors are described in addition to the specific symptom presentation.     

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.     

Obsessive-Compulsive Disorder: Current Views

Obsessive-compulsive disorder has been of central interest to psychoanalysis since Freud's early papers, most particularly in the “Rat Man” case. This early literature spelled out with great clarity the presumed development, psychodynamics, and meaning of obsessional and compulsive symptoms. Unfortunately, since Anna Freud's 1969 review of the subject, virtually nothing has appeared in the psychoanalytic literature that has added to our understanding of the disorder or enhanced the very limited therapeutic influence of psychoanalysis in such cases. Meanwhile, there has been an avalanche of contributions from biological psychiatry and behavioral psychology that have propounded different theories of pathogenesis and have laid claim to significant therapeutic effectiveness. If psychoanalysis is to have credibility in this field, it will have to enlist itself in multidisciplinary research efforts directed toward enriching our knowledge about the psychodynamics and the biological substrate of this illness (more common than once believed) and the efficacy of our efforts to treat it.     

强迫症的脑功能障碍

近期,对强迫症(OCD)的现象学解释强调了病人在特定情境下错误识别和情绪与动机功能的异常加工。来自神经解剖、神经生理以及近期神经心理和功能成像等的相关研究证据显示：OCD病人眶额皮层（OFC）、前扣带回皮层（ACC）的过度激活可能会导致错误识别功能和对行为结果预期的情绪与动机评价增高;背外侧前额皮层(DLPC)的活动减弱损害了对信息加工的认知整合能力。以上这些皮层信号在控制行为活动程序的尾状核进行整合。OCD病人的强迫性观念和行为可能由这些结构相关的神经网络中一个或多个环节的功能障碍所致     

Inhibitory control in Obsessive-Compulsive Disorder

The clinical features of Obsessive-Compulsive Disorder (OCD) suggest that a fundamental deficit of inhibitory control is intrinsic to the disorder. In this preliminary study, we sought to examine cognitive disinhibition in OCD by using an established laboratory technique. The stop signal task was administered to a higher functioning, untreated group of individuals with OCD, and to healthy comparison participants. Surprisingly, the OCD participants exhibited more accurate performance, suggesting better inhibitory control on this task. This unexpected finding suggests that higher functioning individuals with OCD are capable of adequate inhibition in certain contexts. It was speculated, however, that emotional stimulation might negatively affect performance and that this might be studied in subsequent research.     

Obsessive-Compulsive Disorder in the Media

Scholars have long been concerned that mass media depictions of those with mental disorders foster stigma. Research is needed extricating how particular disorders are represented and perceived, such as obsessive-compulsive disorder (OCD). This article examines what images of obsessions and compulsions exist in the media, and how persons interpret these. It employs two methods: qualitative in-depth interviews and content analysis. Data indicate the media represents obsessions and compulsions in distinguishable ways that both reinforce and complicate common media stereotypes of those with mental disorders—fostering a stigma hierarchy and having contradictory effects on mental health literacy.     

Defining Treatment Outcomes in Pediatric Obsessive-Compulsive Disorder Using a Self-Report Scale

This study examined benchmarks of treatment response and clinical remission on the Obsessive Compulsive Inventory–Child Version (OCI-CV) for youth with obsessive-compulsive disorder (OCD). Participants were 91 youth who enrolled in a randomized controlled trial that examined the benefit of augmenting cognitive behavior therapy (CBT) with either d-cycloserine or placebo. Youth completed the OCI-CV at baseline, Week 4 (prior to initiating exposure therapy), and posttreatment. Receiver operator curve (ROC) analyses examined optimal benchmarks for treatment response and clinical remission as identified by independent evaluators at the posttreatment assessment using the Clinical Global Impression (CGI) scales of Improvement (CGI-Improvement), Severity (CGI-Severity), and Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS). Optimal benchmarks for treatment response were a 20%–25% reduction in the OCI-CV total score. Meanwhile, optimal benchmarks for remission were a 55%–65% reduction in the OCI-CV total score and a posttreatment total score ≤ 6-8. OCI-CV benchmarks exhibited moderate agreement with the CY-BOCS for treatment response and clinical remission. Meanwhile, fair agreement was observed for response and remission with CGI scales. A lower pretreatment OCI-CV total score was associated with less agreement between classification approaches. Findings provide benchmarks for classifying treatment response and clinical remission in an efficient manner. Given the moderate agreement between the CY-BOCS and OCI-CV benchmarks, the OCI-CV may serve as a useful alternative when clinician-rated scales cannot be administered due to limited resources (e.g., time, training). Thus, evidence-based measurement can be incorporated to monitor therapeutic response and remission in clinical practice.     

D-Cycloserine for Treatment Nonresponders With Obsessive-Compulsive Disorder: A Case Report

Despite being the most effective treatment available, as many as one third of patients who receive exposure and response prevention (ERP) for obsessive-compulsive disorder (OCD) do not initially respond to treatment. Recent research suggests that the n-methyl d-aspartate (NMDA) receptor partial agonist D-Cycloserine (DCS) may speed up the course of ERP for OCD rather than enhance it. Thus, it is unclear whether DCS would benefit patients who have proven nonresponsive to ERP and serotonin reuptake inhibitors. The present study evaluated the ability of DCS to enhance ERP for 2 patients with OCD who previously had failed to show adequate response to treatment using time-series analysis. Both patients experienced greater reductions with DCS augmented ERP than they did with prior treatment; however, 1 patient relapsed by the 1-month follow-up. DCS augmented ERP might be an effective method for boosting outcomes in individuals who do not readily respond to ERP.