Further evidence for biased semantic networks in Obsessive-compulsive disorder (OCD): When knives are no longer associated with buttering bread but only with stabbing people
Lena Jelinek, Marit Hauschildt, Birgit Hottenrott, Michael Kellner, Steffen Moritz
University Medical Center Hamburg-Eppendorf, Department of Psychiatry and Psychotherapy, Martinistrasse 52, 20246 Hamburg, Germany
Abstract: Background and objectives: Semantic network models suggest that individuals with obsessive-compulsive disorder (OCD) process words with multiple meanings (e.g., "knife") more likely in an OC-related (i.e., "weapon") than in a neutral way (i.e., "cutlery"). Initial evidence was found in an online study. The aim of the current study was to investigate semantic networks in a clinical OCD sample and particularly to identify whether changes in semantic networks following the add-on intervention association splitting (AS) exceeded changes expected through cognitive behavioral therapy (CBT) alone.
Methods: An association task was presented to 36 healthy controls and 70 OCD patients over a period of eight weeks with OCD patients receiving CBT and an add-on intervention (randomized allocation to either AS or a computerized cognitive training). Participants were asked to generate up to five associations to standardized (OC-relevant, negative, neutral) and individual cue words. Associations were rated with regard to OC-relevance and valence.
Results: Analyses revealed that OCD participants produced a) significantly more OC-relevant associations and b) more negative associations than controls for cue words. In the OCD sample, the OC-relevance and valence of associations changed after therapy for personal cue words. This effect was associated with AS at statistical trend level.
Limitations: No clinical control group was recruited; no inter-rater reliability was assessed for the association task.
Conclusions: Further evidence for biased associative networks in OCD was found. Associations of individually chosen cue words proved to be modifiable by therapy.
© 2014 Elsevier Ltd. All rights reserved.
Disgust propensity and contamination-related OCD symptoms: The mediating role of mental contamination
Gabriele Melli, Francesco Bulli, Claudia Carraresi, Eleonora Stopani
Abstract: Fear of contamination within obsessive compulsive disorder (OCD) is traditionally conceptualized as a physical phenomenon. Research has also supported the notion of mental contamination (MC), in which people feel contaminated in the absence of contact with a physical pollutant. In the last decades, a growing number of studies has been centered on the role of disgust propensity (DP) in contamination- related OCD (OCD-C) symptoms. However, the relationship between MC, DP and OCD-C symptoms has not been thoroughly explored. The aims of this study were: (1) to investigate the prevalence of MC in a sample of OCD-C patients; (2) to explore the association between MC, DP and OCD-C symptoms in a sample of OCD patients; and (3) to analyze the role of MC as a mediator in this relationship. Sixty-three patients with OCD-C symptoms completed a series of self-report questionnaires that assessed mental contamination, disgust propensity, OCD symptoms, anxiety, and depression. Significant correlations were found between DP, MC and OCD-C symptoms, controlling for anxiety and depression. Mediation analysis indicated that MC plays a mediating role in the relationship between DP and OCD-C symptoms. These data support the need for specific assessment of MC in clinical settings, particularly where feelings of disgust are involved.
Obsessive–Compulsive Disorder in Adults
Blaise Worden and David F. Tolin
Epidemiological studies typically suggest a lifetime prevalence of obsessive–compulsive disorder (OCD ) in approximately 2% to 3% of adults (Ruscio, Stein, Chiu, & Kessler, 2010; Weissman, Bland, Canino, & Greenwald, 1994). OCD tends to follow a chronic course (Leckman et al., 2010), being unlikely to remit without treatment (Houghton, Saxon, Bradburn, Ricketts, & Hardy, 2010). Adults with OCD report high rates of impairment in work, role (Mancebo et al., 2008), and social functioning (Huppert, Simpson, Nissenson, Liebowitz, & Foa, 2009).
Although the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM–5; American Psychiatric Association, 2013) allows the diagnosis to be made in the presence of either obsessions or compulsions, the vast majority of individuals with OCD present with both (Foa et al., 1995). Obsessions and compulsions tend to cluster into commonly occurring dimensions, with the most common dimensions reflecting (a) fears of contamination paired with washing or cleaning behaviors; (b) "not just right" feelings paired with symmetry or arranging behaviors; and (c) fears of religious blasphemy, aggression, or unwanted sexual thoughts, which can be paired with a variety of compulsions.
The chapter begins with a discussion of cognitive aspects of OCD, describing commonly occurring types of obsessions and other cognitive processes that maintain OCD , such as maladaptive belief systems. We then review behavioral aspects that maintain OCD , such as ritualizing and avoidance. The chapter then covers differential diagnosis of OCD along with empirically supported psychotherapeutic treatments, including cognitive therapy and exposure with response prevention.
(Psychopharmacologic treatments for adult patients are discussed in Chapter 15 of this volume). We conclude with a brief review of other treatment modalities, such as group therapy and self-help formats, and suggestions for future directions in OCD psychotherapy research.
Exposure and Ritual Prevention for Obsessive–Compulsive Disorder: Effects of Intensive Versus Twice-Weekly Sessions
Jonathan S. Abramowitz
Mayo Clinic, Rochester, Minnesota
Edna B. Foa and Martin E. Franklin
University of Pennsylvania School of Medicine
Abstract: Exposure and ritual prevention (ERP) is the most effective treatment for obsessive– compulsive disorder (OCD), yet the intensive treatment schedule often described is not transportable to many settings. In the present study, the authors examined whether a twice-weekly (TW) ERP program reduced the effectiveness of intensive (IT) ERP. Forty OCD patients received 15 sessions of ERP: 20 received daily treatment over 3 weeks and 20 received twice weekly therapy over 8 weeks. Results indicated that both programs were effective. The effect of therapy schedule was moderate, with a trend toward more improvement in the intensive group at post treatment. No differences were found at follow-up; some evidence of relapse was found with IT but not TW.
Introduction: Defining the Scope and Boundaries of the Obsessive–Compulsive Spectrum
Dean McKay and Eric A. Storch
Abstract: Clients’ obsessive, intrusive, and unwanted thoughts and images pose a unique challenge for clinicians. These experiences are difficult to assess objectively given the private nature of the problem. Obsessions are also difficult to treat because clinicians cannot verify the experiences or the success of any treatments beyond the self-report of the client. In the case of obsessive–compulsive disorder (OCD), there are typically overt behavioral signs that imply the presence of obsessions, and these indirect expressions of the underlying mental event serve as our best estimate of the effectiveness of treatments. An added challenge in clinical practice is that many diagnosed conditions have components that resemble obsessions and behaviors that are similar to compulsions. This book focuses on how best to conceptualize and treat the problems of obsessions, compulsions, and the conditions that have signs and symptoms that resemble obsessions and compulsions.
Suicidal and Nonsuicidal Self-Injury in the Obsessive–Compulsive Spectrum
Margaret S. Andover and Blair W. Morris
Little research on suicidal thoughts and behaviors among individuals with OCD exists. This may be because individuals with OCD are considered to be at particularly low risk for suicide on the basis of early reports of low prevalence of suicide deaths within the disorder (Goodwin, Guze, & Robins, 1969). However, more recent research indicates that a significant percentage of patients with anxiety disorders experience suicidal ideation and attempt suicide (Simeon & Hollander, 2006). Specifically, recent prevalence rates suggest that suicidality is more common in OCD than previously thought. Nearly 30% of individuals with a history of attempted suicide and 8% of those reporting suicidal ideation meet diagnostic criteria for OCD specifically (Kessler, Berglund, Borges, Nock, & Wang, 2005). Although prevalence rates vary, researchers have reported that suicide attempts are more common among individuals with OCD than among the general population. Some studies have shown that between 7% and 15% of individuals diagnosed with OCD report a history of attempted suicide (Alonso et al., 2010; Hollander et al., 1996; Sareen et al., 2005; Torres et al., 2007, 2011). However, other studies have reported even higher rates of attempted suicide among individuals with OCD. Between 10% and 25% of individuals with OCD endorse a history of attempted suicide (Angst et al., 2004; Torres et al., 2006, 2007, 2011). Rates of suicidal ideation among individuals with OCD are even higher. Approximately 60% of individuals with OCD report suicidal ideation in their lifetimes (Kamath, Reddy, & Kandavel, 2007; Torres et al., 2006, 2007, 2011), and up to 28% of patients with OCD report current suicidal ideation (Kamath et al., 2007; Torres et al., 2011).
"You can do it!": The role of parental encouragement of bravery in child anxiety treatment
Jennifer S. Silk, Lisa Sheeber, Patricia Z. Tan, Cecile D. Ladouceur, Erika E. Forbes, Dana L. McMakin, Ronald E. Dahl, Greg J. Siegle, Philip C. Kendall, Anthony Mannarino, Neal D. Ryan
Abstract: Individual cognitive-behavioral therapy (CBT) provides anxious youth with skills and experiences to increase "brave" behavior in the face of feared situations. This study addresses whether parental encouragement of bravery during an anxiety provoking and potentially avoidable naturalistic speech task (a) differs between parents of youth (ages 9–13) with anxiety disorders (N = 47) and parents of healthy non-anxious controls (N = 20); (b) influences response to treatment; and (c) changes during treatment for anxious youth randomized to receive CBT (N = 30) or Child-Centered Therapy (CCT; a non-directive active comparison treatment; N = 17). Parent–child dyads were videotaped during a discussion of whether or not the child should complete an optional speech task. Parents of anxious youth showed less encouragement of bravery than parents of controls. Encouragement of bravery increased from pre- to post-treatment for youth who received CBT but not CCT, and pre-treatment encouragement of bravery predicted a better response to treatment, particularly for youth receiving CBT.
When Moral Concerns Become a Psychological Disorder: The Case of Obsessive-Compulsive Disorder
Guy Doron, Dar Sar-El, Mario Mikulincer, and Michael Kyrios
Many of us experience events or thoughts challenging our moral standards but are not flooded by negative self-evaluations, dysfunctional beliefs, and pathological preoccupations. In fact, for most people, such experiences would result in the activation of distress regulation strategies that dissipate unwanted thoughts, reaffirm the challenged self, and restore emotional equanimity. In this chapter, we propose that dysfunctions of the attachment system, as manifested in heightened attachment anxiety, can disrupt the process of coping with morality-related concerns and therefore contribute to OCD. For people with high attachment anxiety, experiences challenging an important self-domain, such as morality, can increase the accessibility of "feared-self" cognitions (e.g., "I’m bad," "I’m immoral") and activate dysfunctional cognitive processes (e.g., an inflated sense of responsibility) that result in the development of obsessional preoccupations.
Clinical Correlates and Genetic Linkage of Social and Communication Difficulties in Families with Obsessive–Compulsive Disorder: Results From the OCD Collaborative Genetics Study
Jack Samuels, Yin Yao Shugart, Ying Wang, Marco A. Grados, O. Joseph Bienvenu, Anthony Pinto, Scott L. Rauch, Benjamin D. Greenberg, James A. Knowles, Abby J. Fyer, John Piacentini, David L. Pauls, Bernadette Cullen, Steven A. Rasmussen, S. Evelyn Stewart, Dan A. Geller, Brion S. Maher, Fernando S. Goes, Dennis L. Murphy, James T. McCracken, Mark A. Riddle, and Gerald Nestadt
Abstract: Some individuals with obsessive–compulsive disorder (OCD) have autistic-like traits, including deficits in social and communication behaviors (pragmatics). The objective of this study was to determine if pragmatic impairment aggregates in OCD families and discriminates a clinically and genetically distinct subtype of OCD. We conducted clinical examinations on, and collected DNA samples from, 706 individuals with OCD in 221 multiply affected OCD families. Using the Pragmatic Rating Scale (PRS), we compared the prevalence of pragmatic impairment in OCD affected relatives of probands with and without pragmatic impairment. We also compared clinical features of OCD-affected individuals in families having at least one, versus no, individual with pragmatic impairment, and assessed for linkage to OCD in the two groups of families. The odds of pragmatic impairment were substantially greater in OCD-affected relatives of probands with pragmatic impairment. Individuals in high-PRS families had greater odds of separation anxiety disorder and social phobia, and a greater number of schizotypal personality traits. In high-PRS families, there was suggestive linkage to OCD on chromosome 12 at marker D12S1064 and on chromosome X at marker DXS7132 whereas, in low-PRS families, there was suggestive linkage to chromosome 3 at marker D3S2398. Pragmatic impairment aggregates in OCD families. Separation anxiety disorder, social phobia, and schizotypal personality traits are part of a clinical spectrum associated with pragmatic impairment in these families. Specific regions of chromosomes 12 and X are linked to OCD in high-PRS families. Thus, pragmatic impairment may distinguish a clinically and genetically homogeneous subtype of OCD.
2014 Wiley Periodicals, Inc.
Pediatric Obsessive–Compulsive Disorder
Michelle R. Gryczkowski and Stephen P. H . Whiteside
The nature and treatment of obsessive–compulsive disorder (OCD) in children and adolescents ages 7 to 17 (henceforth collectively termed children) is largely consistent with that of adults. Diagnostically, the only difference is that children need not recognize that their obsessions or compulsions are irrational. This distinction is supported by recent findings indicating that nearly half of children with OCD demonstrate poor insight into their symptoms (Storch et al., 2008). Children are also more likely than adults to hide their symptoms and have poorer distress tolerance and tend to involve other family members in their rituals (March & Mulle, 1998), rendering treatment more complex. Indeed, pediatric OCD presents unique challenges to the treating clinician and may require therapeutic skills beyond those required to treat adult OCD. Important considerations when assessing and treating pediatric OCD include the developmental level of the child, familial factors that may be maintaining symptoms or providing barriers to treatment, and comorbid externalizing disorders. The purposes of this chapter are to provide a thorough discussion of the nature of pediatric OCD and to offer detailed guidance on its treatment.
Jordana Muroff, Maxwell E. Levis, and Christiana Bratiotis
Hoarding is a serious psychiatric condition that, in its most severe form, can be life-threatening to individuals and a significant burden to community members (Frost, Steketee, & Williams, 2000). Hoarding is associated with severe difficulty discarding everyday possessions and a powerful urge to save objects as well as acquire new ones. These behaviors lead to large amounts of clutter that prevent the use of space for intended purposes, high levels of stress, and impaired daily living (Frost & Hartl, 1996; Saxena, 2008). People who hoard often lack insight about these behaviors (Frost, Tolin, & Maltby, 2010). The Diagnostic and Statistical Manual of Mental Disorders (fifth edition; DSM–5) Obsessive–Compulsive (OC) Spectrum Working Group proposed criteria for hoarding disorder that include specifiers for excessive acquisition and level of insight (American Psychiatric Association, 2011), which were adopted in the DSM–5 (American Psychiatric Association, 2013). Additionally, these symptoms must not be attributable to any other medical or mental health condition (e.g., schizophrenia).