Psychological Flexibility as Shared Process of Change in Acceptance and Commitment Therapy and Exposure and Response Prevention for Obsessive-Compulsive Disorder: A Single Case Design Study

Changes in psychological flexibility were tracked in a combined protocol of exposure and response prevention (ERP) and acceptance and commitment therapy (ACT) for adults with OCD to assess if changes in psychological flexibility processes were unique to ACT intervention (e.g., not impacted by ERP). Using a nonconcurrent multiple baseline design, four participants received sessions of ERP and ACT while data was collected on psychological flexibility processes of change and OCD symptom severity. Results indicate treatment response for three of four participants based on OCD scores. Contrary to predictions, data suggest both ERP and ACT have positive effects on psychological flexibility. Implications of these findings are discussed in relation to recent research on ACT and ERP for OCD. This study also illustrates a type of research design that can be accomplished in clinical practice.     

App-guided exposure and response prevention for obsessive compulsive disorder: an open pilot trial

Although effective treatments for obsessive–compulsive disorder (OCD) exist, there are significant barriers to receiving evidence-based care. Mobile health applications (Apps) offer a promising way of overcoming these barriers by increasing access to treatment. The current study investigated the feasibility, acceptability, and preliminary efficacy of LiveOCDFree, an App designed to help OCD patients conduct exposure and response prevention (ERP). Twenty-one participants with mild to moderate symptoms of OCD were enrolled in a 12-week open trial of App-guided self-help ERP. Self-report assessments of OCD, depression, anxiety, and quality of life were completed at baseline, mid-treatment, and post-treatment. App-guided ERP was a feasible and acceptable self-help intervention for individuals with OCD, with high rates of retention and satisfaction. Participants reported significant improvement in OCD and anxiety symptoms pre- to post-treatment. Findings suggest that LiveOCDFree is a feasible and acceptable self-help intervention for OCD. Preliminary efficacy results are encouraging and point to the potential utility of mobile Apps in expanding the reach of existing empirically supported treatments.     

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.     

Sudden Gains: How Important Are They During Exposure and Response Prevention for Obsessive-Compulsive Disorder?

Symptom reduction over the course of cognitive-behavioral therapy is not always distributed evenly across sessions. Some individuals experience a sudden gain, defined as a large, rapid, and stable decrease in symptoms during treatment. Although research documents a link between sudden gains and treatment for depression and anxiety, findings in the context of obsessive-compulsive disorder (OCD) treatment are mixed. The present study investigated the relationship between sudden gains and treatment outcome in 44 adults with OCD and addressed limitations of previous studies by measuring OCD symptoms dimensionally and comparing individuals who experience sudden gains to those who experience gradual gains of similar magnitude. Sudden gains were observed among 27% of participants, with highest rates among individuals with primary contamination symptoms. Participants who experienced a sudden gain had greater OCD symptom reductions at posttreatment (but not at follow-up), and this difference did not persist after controlling for gain magnitude. Thus, the importance of sudden gains during OCD treatment may be limited. Findings are discussed in light of inhibitory learning models of cognitive-behavioral therapy.     

Behavioral group treatment for obsessive-compulsive disorder in adolescence: a pilot study

This pilot study is a preliminary evaluation of the effectiveness of a cognitive-behavioral outpatient group treatment (CBT) protocol for adolescents with Obsessive-Compulsive Disorder (OCD). Seven adolescents were treated in a 10-session group CBT program with weekly 2-hour sessions. The treatment protocol was an adaptation of approaches with established effectiveness and emphasized three main components: externalizing the OCD by cultivating mindful detachment; exposure and response prevention (ERP); and refocusing on alternative, constructive behaviors following exposure. An occupational therapy component played a significant role in designing creative exposure and refocusing challenges. Self-report measures at pre, post, and 12-month follow-up suggested clinical improvements for 5 of the 7 patients, thus partially supporting a group treatment format for adolescents with mild to moderate OCD.     

Measuring Change in OCD: Sensitivity of the Obsessive-Compulsive Inventory-Revised

This study examined the sensitivity to change and specificity of response of the Obsessive-Compulsive Inventory-Revised (OCI-R), an 18-item self-report measure of obsessive-compulsive disorder (OCD) severity. Seventy-seven OCD patients received cognitive-behavioral therapy incorporating exposure and response prevention (ERP). Change from pre- to posttest on the OCI-R was compared to changes as assessed by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and other measures of OCD and related symptoms. Results suggest the OCI-R is sensitive to treatment effects and that pre- to posttest change on this instrument reflects improvement in OCD and related symptoms of depression, anxiety, and global functioning. The OCI-R was not sensitive to improvement in patients’ insight into the senselessness of their OCD symptoms. The OCI-R appears suitable for use in clinical settings and naturalistic outcome studies where time and resources do not permit administration of lengthy symptom interviews.     

Office-based vs home-based behavioral treatment for obsessive-compulsive disorder: a preliminary study

The current study investigated whether exposure with response prevention (ERP) for obsessive compulsive disorder (OCD) is more effective when administered in a participant's home or other natural environments where symptoms tend to occur, than in a therapist's office. Twenty-eight outpatients with a principal diagnosis of OCD were randomly assigned to receive ERP in their therapist's office vs. wherever their symptoms usually occur (e.g., at home, at work, in public places, in the car, etc.). Participants received 14, 90-min sessions of ERP with an individual therapist. Participants were assessed at pretreatment, post-treatment, and at 3- and 6-month follow-up. Assessments included both self-report as well as clinician-rated indicators of OCD symptom severity, depression, and functional impairment. Results suggested that participants improved significantly, regardless of where treatment occurred. There were no differences in efficacy between the home-based and office-based treatment for OCD. Implications of these findings are discussed.     

Cognitive-behavioral treatment of childhood obsessive-compulsive disorder in community-based clinical practice: clinical significance and benchmarking against efficacy

Objective

To evaluate the feasibility and outcomes of evidence-based (EB) manualized, cognitive-behavioral treatment (CBT) for childhood obsessive-compulsive disorder (OCD), when delivered in an outpatient community-based specialist clinic.

Method

This study, conducted in an outpatient private clinic in South-East Queensland Australia, involved thirty-three children and adolescents with OCD. Children were assessed at pre- and post-treatment, by means of diagnostic interviews, symptom severity interviews, and self-report. Treatment involved 12 sessions CBT delivered either individually or in small groups and included parental involvement.

Results

Manualized CBT could be transported to the community setting effectively, with 63% of the current sample responding positively, based on post-treatment diagnosis. Significant change was evident across a wide-range of outcomes; including, diagnostic severity, symptom severity, child reported depression and anxiety, and both child and parent reported OCD functional impairment.

Conclusions

This study provides evidence for the transportability of manualized CBT in clinical community practice for pediatric OCD. The next important step is larger community based dissemination and effectiveness studies to advance both research and clinical practice outcomes.     

An Open Trial of Group Acceptance and Commitment Therapy With an Adjunctive Mobile App for Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) is a common and debilitating condition. Effective treatments exist, but they are time- and resource-intensive. This study tested the initial efficacy and acceptability of a novel treatment protocol designed to increase efficiency: acceptance and commitment therapy (ACT) taught in groups and through an adjunctive mobile app. Participants were 21 individuals with GAD who received six weeks of 2-hour group ACT sessions as well as access to an adjunctive ACT mobile app. Significant improvements occurred in worry, anxiety, social functioning, and depression as well as relevant processes (psychological inflexibility, anxiety-related cognitive fusion). In-the-moment improvements were also observed in symptoms and ACT processes immediately after completing mobile app sessions. Treatment was perceived as credible and acceptable overall. However, rates of reliable and clinically significant change were low, and app usage did not correlate with change in worry. Overall, this study suggests that an efficient, brief ACT group intervention combined with a mobile app may lead to improvements in GAD but may not be sufficient for clinically significant change. A detailed overview of the treatment is included, and guidance for clinicians interested in implementing this protocol is discussed.     

A Preliminary Examination of the Acceptability,Feasibility, and Effectiveness of a Telehealth Cognitive-Behavioral Therapy Group for Social Anxiety Disorder

In light of the growing interest in, and need for, the telehealth delivery of health care, additional research is needed on the acceptability and effectiveness of these types of interventions. This study examined the acceptability, feasibility, and preliminary effectiveness of an adapted telehealth-delivered group cognitive-behavioral therapy (CBT) intervention for adults with social anxiety disorder (SAD). This report describes the adaptation and subsequent implementation of an 8-week telehealth-delivered group treatment designed to reduce symptoms of SAD. Specific adaptations for delivering treatment during the COVID-19 pandemic and the subsequent enactment of social distancing measures are discussed. Posttreatment data indicated that the intervention was feasible to implement in an outpatient mental health clinic, acceptable to participants, and associated with reduction in symptoms of social anxiety, general anxiety, depression, and stress.     

Acceptance and Commitment Therapy With Older Adults: Rationale and Considerations

Older adults are the fastest growing segment of the population. With these changing demographics, mental health professionals will be seeing more older clients. Additionally, older adults are an underserved population in that most older adults in need of mental health services do not receive treatment. Thus, it is essential that treatments for mental and behavioral health problems are empirically supported with older adults and that mental health professionals are aware of the special needs of older adult populations. Acceptance and Commitment Therapy (ACT) is an emerging approach to the treatment of distress. The purpose of this article is to provide a rationale for using ACT with older adults based on gerontological theory and research. We also review research on ACT-related processes in later life. We present a case example of an older man with depression and anxiety whom we treated with ACT. Finally, we describe treatment recommendations and important adaptations that need to be considered when using ACT with older adults and discuss important areas for future research.     

A randomized trial of ACT bibliotherapy on the mental health of K-12 teachers and staff

The mental health challenges of some vocations present a challenge for current intervention models. Bibliotherapy focused on transdiagnostic processes that might both prevent and alleviate a range of mental health distress could be an effective and practical approach. K-12 school personnel (N = 236; 91% female; 30-60 years old) responding to a wellness-oriented program announcement were randomized to receive an Acceptance and Commitment Therapy (ACT) self-help volume or to a waitlist. Three-fourths were above clinical cutoffs in general mental health, depression, anxiety, or stress. Participants read the book for two months, completed exercises and quizzes, and after post assessment were followed for 10 weeks; waitlist participants were then also given the book with two months to complete it. Overall, participants showed significant improvement in psychological health. Significant preventive effects for depression and anxiety were observed along with significant ameliorative effects for those in the clinical ranges of depression, anxiety and stress. Follow up general mental health, depression, and anxiety outcomes were related to the manner in which participants used the workbook and to post levels of psychological flexibility.     

Mindfulness and Acceptance-Based Group Therapy for Social Anxiety Disorder: An Open Trial

Mindfulness and Acceptance-Based Group Therapy (MAGT) for Social Anxiety Disorder (SAD) is based largely on Acceptance and Commitment Therapy (ACT; Hayes et al., 1999), with enhanced mindfulness mostly from Mindfulness-Based Cognitive Therapy (MBCT; Segal et al., 2002). The purpose of this study was to assess the feasibility and initial effectiveness of MAGT for the treatment of SAD. Forty-two SAD patients were invited to take part in an open trial of MAGT. Participants completed measures of social anxiety, mindfulness and acceptance, depression, and rumination at pretreatment, midtreatment (6 weeks), posttreatment (12 weeks), and at a 3-month follow-up session. Twenty-nine participants completed the treatment and these participants reported that the treatment was helpful. Effect sizes for treatment completers ranged from 1.00 to 1.17 for the social anxiety symptom measures at follow-up. Intent-to-treat analyses revealed significant reductions in social anxiety, depression, and rumination and significant increases in mindfulness and acceptance, with effect sizes ranging from .65 to .76 on the social anxiety measures. This study demonstrates that MAGT is feasible and acceptable to SAD patients and provides further support for the use of mindfulness and acceptance-based interventions for the treatment of SAD.     

Does Exposure and Response Prevention Behaviorally Activate Patients With Obsessive-Compulsive Disorder? A Preliminary Test

Exposure and response prevention (ERP) and behavioral activation (BA) are effective treatments for obsessive-compulsive disorder (OCD) and depression, respectively. Patients with OCD often exhibit depression; furthermore, ERP for OCD is associated with reduced depressive symptoms. To our knowledge, no study has examined whether ERP itself functions to behaviorally activate patients with concurrent OCD and depressive symptoms. This prospective study was designed to test the hypotheses that (a) OCD exposure hierarchy completion, increased BA, and depressive symptom reduction would all be related, and (b) pre- to posttreatment changes in BA would mediate the direct effect of OCD hierarchy completion on posttreatment depressive symptoms, even after controlling for pretreatment depressive symptoms, pretreatment BA, pre- to posttreatment reductions in OCD symptoms, treatment duration, and antidepressant medication use. Patients (N = 90) with a primary diagnosis of OCD who received residential ERP for OCD completed a self-report battery at pre- and posttreatment. Exposure hierarchy completion, increases in BA, and decreases in depression were all significantly correlated (rs ranged .33 to .44). The effect of hierarchy completion on posttreatment depressive symptoms was fully mediated by pre- to posttreatment changes in BA. Findings highlight the potential for ERP to exert antidepressant effects by behaviorally activating patients. Limitations, clinical implications, and future directions are discussed.     

Depression and Anxiety in Older and Middle‐aged Adults With Diabetes

This study aims to compare rates of depressive and anxious symptoms among older adults with and without diabetes. The study also examines differences in depression, anxiety, and diabetes‐related emotional distress between middle‐aged and older adults with diabetes. A total of 224 participants completed a range of questionnaires measuring depression, anxiety, and diabetes‐related emotional distress (if applicable). One hundred and three adults with diabetes (55 middle‐aged, mean age = 47 years, range 40–59 years and 48 older, mean age = 69 years, range 60–81 years) were recruited from a tertiary diabetes clinic. One hundred and twenty‐one adults without diabetes (72 middle‐aged, mean age = 52 years, range 40–59 years and 49 older, mean age = 65 years, range 60–76 years) were recruited from either a university student pool or a registry of adults aged 50 and above. Older adults with diabetes had significantly higher levels of depression and comparable levels of anxiety with older adults without diabetes. Older adults with diabetes had significantly lower levels of depression, anxiety, and diabetes‐related distress than middle‐aged adults with diabetes. Diabetes is associated with high rates of depression and anxiety, with middle‐aged adults more adversely affected than older adults.     

Behavioral Therapy Teams for Obsessive-Compulsive Disorder: Lessons Learned From a Pilot Randomized Trial in a Community Mental Health Center

Community mental health centers (CMHCs) provide the majority of mental health services for low-income individuals in the United States. Exposure and response prevention (ERP), the psychotherapy of choice for obsessive-compulsive disorder (OCD), is rarely delivered in CMHCs. This study aimed to establish the acceptability and feasibility of testing a behavioral therapy team (BTT) intervention to deliver ERP in CMHCs. BTT consisted of individual information-gathering sessions followed by 12 weeks of group ERP and concurrent home-based coaching sessions. The sample consisted of 47 low-income individuals with OCD who were randomized to receive BTT or treatment as usual (TAU). Symptom severity and quality-of-life measures were assessed at pretreatment, posttreatment, and 3- and 6-month posttreatment. Feasibility of training CMHC staff was partially successful. CMHC therapists successfully completed rigorous training and delivered ERP with high fidelity. However, training paraprofessionals as ERP coaches was more challenging. ERP was feasible and acceptable to patients. BTT participants were more likely than TAU participants to attend their first therapy session and attended significantly more treatment sessions. A large between-group effect size was observed for reduction in OCD symptoms at posttreatment but differences were not maintained across 3- and 6-month follow-ups. For BTT participants, within-group effect sizes reflecting change from baseline to posttreatment were large. For TAU participants, depression scores did not change during the active treatment phase but gradually improved during follow-up. Results support feasibility and acceptability of ERP for this patient population. Findings also underscore the importance of implementation frameworks to help understand factors that impact training professionals.     

School-Based Acceptance and Commitment Therapy for Adolescents With Anxiety: A Pilot Trial

Anxiety disorders are one of the most prevalent diagnoses in youth, often resulting in impaired social and school functioning. Research on treatments for youth anxiety is primarily based in traditional clinical settings. However, integrating youth psychotherapies into the school environment improves access to evidence-based care. The present study is a pilot, randomized waitlist-controlled trial of a school-based, group Acceptance and Commitment Therapy–based (ACT) intervention for adolescents with anxiety. Students at two separate schools (N = 26) with elevated anxiety were randomized to a 12-week waitlist or to immediate treatment. Participants in the immediate treatment condition reported statistically significant decreases in anxiety and class absences at posttreatment and follow-up compared to the waitlist group. No statistically significant differences were found between groups for depression, psychological flexibility, positive mental health, and student well-being. However, medium within-condition effect sizes were seen in the treatment group for all outcomes. Participants reported the treatment as favorable with good acceptance ratings. Overall, this study supports ACT as a viable intervention for schools and other clinical settings providing services to adolescents with anxiety.     

Mental Contamination in Obsessive-Compulsive Disorder: Associations With Contamination Symptoms and Treatment Response

The most common symptom of obsessive-compulsive disorder (OCD) is contamination fear. Feelings of contamination can be provoked through contact with a physical contaminant, referred to as contact contamination (CC), as well as in the absence of one, referred to as mental contamination (MC). Prior research indicates that CC and MC are distinct, and MC may interfere with treatment for CC. However, no study to date has examined how MC may be associated with responses to physical contaminants and treatment response for CC. This study examined the relationships between CC and MC in a sample of individuals with elevated contamination symptoms (N = 88), half of whom met diagnostic criteria for OCD. Participants engaged in three sessions of exposure and response prevention (ERP) for CC and completed self-report measures and behavioral tasks assessing CC and MC at pretreatment, posttreatment, and follow-up. As hypothesized, at pretreatment, MC was positively associated with reactivity to physical contaminants, even after participants washed their hands. ERP for CC was associated with unique changes in CC and MC across self-report and behavioral measures, and greater pretreatment MC predicted greater posttreatment CC, though this effect was evident in only one of two CC measures. Additionally, specificity analyses indicated changes in MC were independent of changes in disgust propensity, a related construct. Pretreatment disgust propensity also predicted treatment outcome, though the addition of pretreatment disgust propensity as a covariate reduced the relationship between pretreatment MC and posttreatment CC to nonsignificance. Results suggest MC plays an important role in the manifestation and treatment of CC symptoms and may represent a manifestation of disgust proneness. Theoretical and clinical implications are discussed.     

Obsessive-Compulsive Disorder in Late Life

Although obsessive-compulsive disorder (OCD) has received increasing attention, the study and treatment of OCD in late life has been neglected. The obsessions and compulsions seen with older adults do not appear to differ from the symptoms experienced by other age groups, although developmental issues might influence symptom focus (e.g., memory functioning-related obsessions). Hoarding difficulties might be prevalent in late life, although additional studies are needed. Seniors with OCD can present with comorbid psychiatric disorders, multiple general medical problems, and impaired cognitive functioning, complicating evaluation. There have not been controlled clinical trials of cognitive-behavioral therapy (CBT) for late-life OCD, although initial reports suggest older adults respond to CBT that includes age-related treatment modifications. We illustrate the challenges to assessing and treating older adults with OCD with case examples involving memory-related obsessions and clinical hoarding. The successful strategies used for adapting CBT for the treatment of late-life generalized anxiety disorder might serve as a model for advancing the study and treatment of late-life OCD.     

Characteristics and Effectiveness of an Intensive Military Outpatient Treatment Program for PTSD

This study describes the characteristics and global effectiveness of treatment of a military intensive outpatient treatment program for posttraumatic stress disorder (PTSD). Thirty-nine military personnel completed treatment outcome questionnaires. Results showed a statistically significant reduction in depression and PTSD symptoms after the participants completed 3 weeks of intensive outpatient therapy. The findings have clinical and research implications for the length, intensity, and focus of PTSD treatment.