Cognitive Behavior Therapy for Obsessions and Compulsions: New Applications and Emerging Trends

This paper describes recent developments in the cognitive behavioral treatment (CBT) of obsessive compulsive disorder (OCD). Although behavioral treatment of OCD consisting of exposure and response prevention (ERP) has been shown to be clinically effective, certain limitations with ERP have led clinical researchers to propose that treatment should be augmented with direct cognitive interventions. Modification of dysfunctional beliefs and faulty appraisals or interpretations of the obsession are now considered a crucial component of CBT for obsessions and compulsions. This paper discusses the conceptual basis of the new CBT for OCD and reviews its limited empirical status. A case example is provided in which CBT is used to treat obsessional ruminations of becoming sick. The article concludes with a discussion of the challenges and pitfalls involved in offering CBT for obsessions and compulsions.     

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.     

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.     

Examining the Experience of Undergoing Group Cognitive Behavioral Therapy for Obsessive Compulsive Disorder: An Interpretative Phenomenological Analysis

This study used interpretative phenomenological analysis (IPA) to explore the lived experiences of five individuals diagnosed with obsessive-compulsive disorder (OCD) who underwent a group cognitive behavioral therapy (CBT) intervention program to address their symptoms. Two master themes were identified: experiences and processes of change and reflections on change. For all participants, the degree of group cohesion or connectedness they established with group members emerged as highly important in facilitating therapeutic progress. A number of technical elements of cognitive behavioral therapy (CBT) were also notable therapeutic factors, including questioning/rationalizing maladaptive interpretations about intrusions. However, the commonality of non-specific group processes as key features for subsequent therapeutic change prompts the need for further research in dynamics within CBT group interventions for OCD.     

Do traumatic events influence the clinical expression of compulsive hoarding?

Traumatic experiences have been posited as one potential catalyst for the abrupt onset of obsessive-compulsive symptoms including compulsive hoarding. To determine whether traumatic life events (TLEs) might influence the expression of compulsive hoarding in obsessive-compulsive disorder (OCD), interview responses to the Posttraumatic Stress Disorder module of the Structured Clinical Interview for DSM-IV (SCID) were examined in 180 individuals with OCD. Compared to individuals with OCD who did not meet criteria for hoarding, participants classified as hoarders (24% of the sample) were significantly more likely to have reported at least one TLE in their lifetime. Patients who met criteria for hoarding and who had also experienced TLEs had significantly greater hoarding symptom severity than those hoarders not exposed to trauma. This association was found to be robust. That is, the relationship between TLEs and hoarding symptom severity was not better accounted for by age, age of OCD onset, depressive symptoms, general OCD symptomatology, or mood and anxiety comorbidity. Closer examination revealed that the clutter factor of compulsive hoarding (and not difficulty discarding or acquisitioning) was most strongly associated with having experienced a traumatic event.     

The structure of childhood obsessions and compulsions: dimensions in an outpatient sample

While obsessive-compulsive disorder (OCD) is defined as a unitary condition, prior research has identified meaningful and distinct symptom dimensions in adult samples. In contrast, there have been no investigations of symptom dimensions in samples of children diagnosed with OCD. The present study sought to address this gap. Children diagnosed with OCD (n = 137) were administered the Children's Yale-Brown Obsessive-Compulsive Scale symptom checklist and severity index. Symptoms were analyzed using principal components analysis. As with adult samples, four factors were identified from the checklist. However, these four factors (compulsions, sexual/aggressive obsessions, superstitions, and hoarding/ordering/somatic concerns) were different in content from adult studies. Further, several symptoms significantly contributed to more than one dimension. Each dimension was significantly correlated with scores from the severity index, with the exception of the obsession score with the hoarding/ordering/somatic concerns factor. Results suggest that there are distinct dimensions of symptoms in childhood OCD, but that these dimensions do not correspond to those identified in adults. Instead, it appears that some factors share variance, and the dimensions themselves are separated based upon developmental trajectories. The dimensions examined may be useful in future treatment studies using pharmacological and/or behavioral interventions.     

The status of hoarding as a symptom of obsessive-compulsive disorder

Hoarding is considered by many to be a symptom of obsessive-compulsive disorder (OCD). Yet although it is observed in people with OCD, hoarding symptoms also appear in a number of other psychological and psychiatric conditions. The present studies were conducted using samples of OCD patients, patients with other anxiety disorders, and a non-clinical sample to further elucidate the relationship between hoarding and OCD. Across two investigations, we found that (a) whereas OCD patients had higher scores than the other groups on non-hoarding symptoms, this was not the case for hoarding symptoms; (b) hoarding tended to correlate more weakly with other OCD symptoms (e.g., washing, checking) than these other symptoms intercorrelated; (c) items measuring hoarding had the weakest factor loadings when a measure of OCD symptoms was submitted to factor analysis; (d) hoarding symptoms were not correlated with global OCD or anxiety severity, whereas other OCD symptoms were; and (e) hoarding did not show consistent relationships with OCD-related cognitive variables. These results do not support a specific relationship between hoarding and OCD; and they call into question hoarding's status as a specific symptom of OCD. Results are also discussed in terms of the importance of functional assessment of hoarding and OCD symptoms.     

Hoarding in obsessive-compulsive disorder: results from the OCD Collaborative Genetics Study

Hoarding behavior occurs frequently in obsessive-compulsive disorder (OCD). Results from previous studies suggest that individuals with OCD who have hoarding symptoms are clinically different than non-hoarders and may represent a distinct clinical group. In the present study, we compared 235 hoarding to 389 non-hoarding participants, all of whom had OCD, collected in the course of the OCD Collaborative Genetics Study. We found that, compared to non-hoarding individuals, hoarders were more likely to have symmetry obsessions and repeating, counting, and ordering compulsions; poorer insight; more severe illness; difficulty initiating or completing tasks; and indecision. Hoarders had a greater prevalence of social phobia and generalized anxiety disorder. Hoarders also had a greater prevalence of obsessive-compulsive and dependent personality disorders. Five personality traits were independently associated with hoarding: miserliness, preoccupation with details, difficulty making decisions, odd behavior or appearance, and magical thinking. Hoarding and indecision were more prevalent in the relatives of hoarding than of non-hoarding probands. Hoarding in relatives was associated with indecision in probands, independently of proband hoarding status. The findings suggest that hoarding behavior may help differentiate a distinct clinical subgroup of people with OCD and may aggregate in some OCD families. Indecision may be a risk factor for hoarding in these families.     

Videoconferencing-based cognitive-behavioral therapy for obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a prevalent, chronic and disabling anxiety disorder. Despite the efficacy and strength of pharmacologic interventions for OCD, medications are not always well accepted or effective, making an efficacious psychosocial alternative especially attractive. Cognitive-behavioral therapy (CBT) has been established as an effective treatment for adult OCD, yet access to such treatment is limited, especially in rural areas. Technological advances allow for therapy to be provided in a real-time format over a videoconferencing network. This method allows therapists to provide state-of-the-art treatment to patients who would not otherwise have access to it. This paper presents three cases of OCD successfully treated via videoconferencing CBT. The presence of OCD was established via structured clinical interview and clinician-rated outcome measures were completed by evaluators blinded to the method of treatment. A multiple baseline across individuals design was used to support the internal validity of the CBT outcome data. Patient ratings of therapeutic alliance were high across all three cases. Information gathered from qualitative interviews post-treatment confirmed quantitative measures finding high levels of patient satisfaction. This pilot study suggests that videoconferencing-based CBT is a promising method to bring appropriate treatment to thousands who live far distances from well-trained therapists.     

强迫症诊断研究的新变化

临床实践与相关研究表明,强迫症的诊断标准已不能满足复杂的临床工作需要。首先,有关患者的自知力以及主观痛苦程度等诊断指标需要进一步修订。其次,就强迫症的核心症状而产生的争议,研究者提出应重新考虑强迫症、焦虑障碍、强迫谱系障碍和囤积障碍这四个概念之间的从属关系和诊断标准。未来研究应考虑从认知神经科学的视角探索强迫症的核心症状和病理机制,为强迫症的诊断标准提供新的依据。     

Cognitive Behavioral Therapy for Attention-Deficit/Hyperactivity Disorder in College Students: A Review of the Literature

The current review presents a theory-guided review of the existing cognitive behavioral therapy (CBT) interventions for attention-deficit/hyperactivity disorder (ADHD) in college students. Across the eight studies that investigated this topic, moderate reductions were shown in inattentive symptoms but little to no change was reported in hyperactive/impulsive symptoms. Results indicated a moderate treatment effect on self-reported quality of life and school/work functioning, yet less of an impact on GPA, response inhibition, social functioning, and executive functioning. Methodological and statistical problems and inconsistencies were noted. Since college students are emerging adults, it is likely that the optimum CBT intervention for college students with ADHD lies somewhere in between the existing clinic-based adult ADHD CBT interventions as well as the school-based adolescent ADHD psychosocial interventions. Directions for future research and recommendations for clinicians in university settings are provided in an attempt to further develop the existing college students CBT clinical research evidence base.     

Hoarding and its relation to obsessive-compulsive disorder

Although hoarding is observed in some patients with obsessive-compulsive disorder (OCD), it has not been shown to share a specific relation with OCD. Across two studies, we found that (a) whereas the classic OCD symptoms of checking, rituals, and contamination intercorrelated consistently strongly with one another, hoarding related only moderately to both these OCD symptoms and to depression; (b) OCD patients were distinguished from both other patients and non-patients by classic OCD symptoms, but not by hoarding; and (c) whereas OCD symptoms showed consistent relations with Negative Affect, hoarding largely was uncorrelated with this dimension. These results do not support a specific OCD-hoarding relation but rather call into question the trend of considering it a specific symptom of OCD.     

Hoarding in obsessive compulsive disorder: results from a case-control study

Hoarding occurs relatively frequently in obsessive-compulsive disorder (OCD), and there is evidence that patients with hoarding symptoms have more severe OCD and are less responsive to treatment. In the present study, we investigated hoarding symptoms in 126 subjects with OCD. Nearly 30% of the subjects had hoarding symptoms; hoarding was twice as prevalent in males than females. Compared to the 90 non-hoarding subjects, the 36 hoarding individuals had an earlier age at onset of, and more severe, obsessive-compulsive symptoms. Hoarders had greater prevalences of symmetry obsessions, counting compulsions, and ordering compulsions. Hoarders also had greater prevalences of social phobia, personality disorders, and pathological grooming behaviors (skin picking, nail biting, and trichotillomania). Hoarding and tics were more frequent in first-degree relatives of hoarding than non-hoarding probands. The findings suggest that the treatment of OCD patients with hoarding symptoms may be complicated by more severe OCD and the presence of co-occurring disorders. Hoarding appears to be transmitted in some OCD families and may differentiate a clinical subgroup of OCD.     

Group versus individual cognitive-behavioural treatment for obsessive-compulsive disorder: a controlled trial

The efficacy of group cognitive behaviour therapy (CBT) for obsessive-compulsive disorder (OCD) has received relatively little research attention compared with the large number of studies that have investigated individual CBT. The current study is the first controlled study to compare an identical CBT protocol, containing both cognitive and behavioural elements, delivered either individually or in a group. Participants were randomly assigned to either 10 weeks of individual CBT, 10 weeks of group CBT or a 10 week wait-list. Participants with significant rates of secondary comorbidity were included in the study to enhance the generalisability of results. Intention-to-treat and completer analyses were carried out and indicated no differences between the group and individual treatments on outcome measures. Large effect sizes were found for both conditions. Analysis of clinically significant change indicated that the individual treatment was associated with a more rapid response but that both treatments had equivalent rates of recovered participants by brief follow-up. The importance of further investigations of the efficacy of group CBT for OCD is discussed.     

Measurement of compulsive hoarding: saving inventory-revised

Four studies examined a new measure of compulsive hoarding (Saving Inventory-Revised; SI-R). Factor analysis using 139 hoarding participants identified 3 factors: difficulty discarding, excessive clutter, and excessive acquisition. Additional studies were conducted with hoarding participants, OCD participants without hoarding, community controls and an elderly sample exhibiting a range of hoarding behavior. Internal consistencies and test-retest reliabilities were good. The SI-R distinguished hoarding participants from all other non-hoarding comparison groups. The SI-R showed strong correlations with other indices and methods of measuring hoarding (beliefs, activity dysfunction from clutter, observer ratings of clutter in the home) and relatively weaker correlations with non-hoarding measures (positive and negative affect and OCD symptoms). The SI-R appears to be an appropriate instrument for assessing symptoms of compulsive hoarding in clinical and non-clinical samples.     

Hoarding behaviors in a large college sample

Hoarding behaviors occur in many clinical syndromes but are most commonly linked to obsessive compulsive disorder. Surprisingly little empirical work has examined the nature of hoarding behaviors despite their association with significant distress and impairment. The current study examined hoarding in 563 unselected college students. Using principal components analysis, we identified four domains of hoarding behaviors as measured by the 26-item Saving Inventory-Revised: Difficulty Discarding, Acquisition Problems, Clutter, and Interference/Distress. All four domains and total hoarding behaviors were strongly related to hoarding beliefs and to obsessive compulsive (OC) symptoms. Hoarding behaviors were most strongly correlated with subscales of an OC disorder (OCD) measure assessing hoarding and obsessions and least strongly correlated with the washing subscale. Hoarding behaviors also showed significant, but more modest, correlations with social anxiety, depressive symptoms, and worry. However, worry was not found to contribute unique variance to the prediction of hoarding behaviors. Of greatest note, hoarding behaviors showed a surprisingly strong relationship with anxiety sensitivity, similar in magnitude to the relationship between hoarding and OCD symptoms. Results are interpreted and lines of future research are proposed, with particular emphasis on further elucidating the relationship between hoarding behaviors and anxiety sensitivity.     

Group cognitive-behavioral therapy for hoarding disorder: an open trial

Although cognitive-behavioral therapy (CBT) appears to be a promising treatment approach for hoarding disorder, treatment to date has been quite labor intensive. The goal of this study, therefore, was to assess the potential effectiveness of group CBT for hoarding, without home visits by the clinician. Forty-five individuals with hoarding disorder enrolled in either a 16 or 20 session program of group CBT; 30 (67%) completed treatment. Using mixed-effects models to account for missing data, we report data from 35 (78%) participants who provided enough data for analysis. Participants demonstrated significant improvements in hoarding symptoms, as well as symptoms of depression and anxiety, and quality of life. Improvements in hoarding symptoms were comparable to two published clinical trials on individual CBT for hoarding disorder. Results of this study suggest that group CBT for hoarding, without home discarding sessions by the clinician, may be an effective treatment option with the potential advantage of increasing treatment access by reducing clinician burden and cost of treatment.     

Cognitive behavior therapy in treatment-naive children and adolescents with obsessive-compulsive disorder: an open trial

This work aims is to evaluate the therapeutic efficacy of cognitive behavior therapy (CBT) in pediatric patients with obsessive-compulsive disorder (OCD) who had not previously been treated with either pharmacotherapy or psychotherapy and who remained medication-free during CBT. Sixteen OCD outpatients, 8-17 years of age, were treated in a 12-week open trial with manualized CBT. Target symptoms were rated at two-week intervals with the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS), the National Institute of Mental Health Global Obsessive-Compulsive Scale (NIMH Global), the Clinical Global Impression Scale (CGI), and the Hamilton Anxiety Rating Scale (Ham-A). Statistical analyses showed a significant benefit for treatment. Ten patients experienced at least a 50% reduction in symptoms on the CY-BOCS; seven were asymptomatic on the NIMH Global. These results build on previous reports that CBT may be effective in the acute treatment of pediatric OCD. Further, the results of this study suggest that CBT can be efficacious in alleviating OCD symptoms in the absence of pharmacotherapy. These results must be considered preliminary, given the small sample size and open administration of treatment.     

Patient utilization of cognitive-behavioral therapy for OCD

The current study examined utilization of cognitive-behavioral therapy (CBT) by individuals receiving treatment for obsessive-compulsive disorder (OCD). Participants were 202 adults with primary DSM-IV OCD who enrolled in a longitudinal, observational study of the course of OCD and completed 2 years of annual follow-up interviews using the Longitudinal Interval Follow-Up Evaluation. One hundred twenty participants reported that a mental health professional recommended CBT for their OCD symptoms at some point during the 2-year follow-up period. One quarter (n = 31) of these participants did not initiate CBT despite receiving a treatment recommendation. Thirty-one percent of the 89 participants who entered CBT endorsed dropping out of CBT prematurely and less than one third received an adequate “dose” of CBT sessions. Self-reported CBT drop-out rates were significantly greater than attrition rates reported in clinical trials using intensive schedules of exposure and ritual prevention (EX/RP). Perceived environmental barriers and fears regarding treatment participation were the most frequently endorsed reasons for not participating or dropping out of CBT. Despite its efficacy for OCD, many individuals with clinically significant symptoms fail to initiate CBT when recommended by a mental health professional, receive treatments that are less intensive than those used in clinical trials, or drop out of treatment prematurely. Financial costs of CBT, difficulty attending sessions, and fears regarding treatment are significant barriers to initiating and completing therapy.