Georgina Krebs

The effects of modifying interpretation bias on worry in generalized anxiety disorder

This study investigated whether facilitating a benign interpretive bias decreases negative thought intrusions in generalized anxiety disorder (GAD). Clients were randomly allocated to an interpretation modification condition in which they repeatedly accessed benign meanings of emotionally ambiguous homographs and scenarios, or to a control condition in which they accessed threat and benign meanings with equal frequency. Worry frequency was assessed using a breathing focus task that involved categorising the valence of thought intrusions before and after an instructed worry period. Interpretation bias was assessed during the modification tasks, and on a different measure of interpretation bias (sentence completion) following a period of worry. The experimental procedure modified interpretations made during training, and in the later sentence completion task. Furthermore, compared to the control group, the benign group showed fewer negative thought intrusions during breathing focus (as rated by both participants and an assessor). These findings show that it is possible to induce a more benign interpretive bias in GAD clients and that this reduces negative thought intrusions.

The effect of attention modification with explicit vs. minimal instructions on worry.

In this experiment we investigated the effect of different instructions on the modification of attentional biases, and subsequently on worry persistence. Participants without excessive worry completed a modified dot-probe task, designed to train attention either to threat or neutral words. Half of each group was given explicit instructions regarding the relationship between word valence and target location, and half were given the more usual minimal instructions. Impact on worry persistence was assessed by categorizing the valence of thought intrusions before and after a period of instructed worry. Response latencies to test items on the dot-probe task showed that attention had been successfully manipulated in the expected direction, and explicit instructions led to more effective attention modification. Moreover, participants in the attend-threat group who received explicit instructions reported significantly more negative thought intrusions following instructed worry, as rated by an assessor, whereas participants in the attend-neutral group did not. These findings suggest that an attentional bias towards threatening information plays a role in worry persistence, and that explicit instructions may be helpful in modifying this bias.

Children with very early onset obsessive-compulsive disorder: clinical features and treatment outcome

BACKGROUND There is emerging evidence that early onset obsessive-compulsive disorder (OCD) may be a phenomenologically distinct subtype of the disorder. Previous research has shown that individuals who report an early onset display greater severity and persistence of symptoms, and they may be less responsive to treatment. To date, this question has been investigated solely in adult samples. The present study represents the first investigation into the effect of age at onset of OCD on clinical characteristics and response to treatment in a paediatric sample. METHOD A total of 365 young people referred to a specialist OCD clinic were included in the study. Clinical records were used to examine potential differences in key clinical characteristics between those who had a very early onset of the disorder (before 10 years) and those who had a late onset (10 years or later). Group differences in treatment responsiveness were also examined within a subgroup that received cognitive behaviour therapy (CBT) alone or CBT plus medication (n = 109). RESULTS The very early onset group were characterised by a longer duration of illness, higher rates of comorbid tics, more frequent ordering and repeating compulsions and greater parent-reported psychosocial difficulties. There were no differences in treatment response between the groups, and when age at onset was examined as a continuous variable, it did not correlate with treatment response. CONCLUSIONS Very early onset OCD may be associated with different symptoms and comorbidities compared with late onset OCD. However, these differences do not appear to impact on responsiveness to developmentally tailored CBT alone or in combination with medication. These findings further indicate the value in early detection and treatment of OCD in childhood.

Cognitive-behavioural therapy with post-session d-cycloserine augmentation for paediatric obsessive-compulsive disorder: pilot randomised controlled trial

A partial N-methyl-D-aspartate agonist, D-cycloserine, enhances fear extinction when given before or shortly after exposure to feared stimuli in animals. In this pilot double-blind placebo-controlled trial (trial number: ISRCTN70977225), 27 youth with obsessive-compulsive disorder were randomised to either 50 mg D-cycloserine or placebo administered immediately after each of ten cognitive-behavioural therapy (CBT) sessions, primarily consisting of exposure and ritual prevention. Both groups improved significantly and maintained their gains at 1-year follow-up, with no significant advantage of D-cycloserine over placebo at any time point. The effects of CBT may not be augmented or accelerated when D-cycloserine is administered after sessions.

Babies of a pandemic

Infant development and maternal HIV The effect of maternal HIV on infant development is a major concern because the virus has become so widespread among women of childbearing age. According to a United Nations report published in October 2003, half the new cases of HIV infection that occur across the world each year are among 15–24 year olds.1 This group, constituting two and a half million people, are the next generation of parents. The situation is particularly catastrophic in sub-Saharan Africa where widespread poverty and underdevelopment already undermine children’s health and wellbeing.2 It is estimated that 10 million people in this region between the ages of 15 and 24, and up to 45% of pregnant women, are infected.3 With this recognition of the high prevalence of HIV in pregnant women in parts of sub-Saharan Africa, major efforts have been directed at developing and implementing interventions to prevent mother-to-child transmission. These efforts have been largely successful: antiretroviral medication, caesarean section, and locally appropriate feeding practice can now reduce transmission from 40% to below 10%.4 In sub-Saharan Africa these interventions are unfortunately not widely available, but nonetheless, it is still the minority of children who are infected.4 Orphaning is increasing in sub-Saharan Africa as rates of adult mortality have started to accelerate.5 However, by far the largest group of vulnerable young children are those living with an HIV infected mother. In sub-Saharan Africa approximately 70% of infected mothers survive for at least the first five years of their children’s lives,6 and this number will increase with the rollout of antiretroviral medication. It is known that the early years of life are crucial for a child’s development, and it is likely that maternal HIV disrupts the rearing environment, thereby putting these children at risk. A key …

Telephone cognitive-behavioral therapy for adolescents with obsessive-compulsive disorder: a randomized controlled non-inferiority trial.

Objective Many adolescents with obsessive-compulsive disorder (OCD) do not have access to evidence-based treatment. A randomized controlled non-inferiority trial was conducted in a specialist OCD clinic to evaluate the effectiveness of telephone cognitive-behavioral therapy (TCBT) for adolescents with OCD compared to standard clinic-based, face-to-face CBT. Method Seventy-two adolescents, aged 11 through 18 years with primary OCD, and their parents were randomized to receive specialist TCBT or CBT. The intervention provided differed only in the method of treatment delivery. All participants received up to 14 sessions of CBT, incorporating exposure with response prevention (E/RP), provided by experienced therapists. The primary outcome measure was the Children’s Yale–Brown Obsessive-Compulsive Scale (CY-BOCS). Blind assessor ratings were obtained at midtreatment, posttreatment, 3-month, 6-month, and 12-month follow-up. Results Intent-to-treat analyses indicated that TCBT was not inferior to face-to-face CBT at posttreatment, 3-month, and 6-month follow-up. At 12-month follow-up, there were no significant between-group differences on the CY-BOCS, but the confidence intervals exceeded the non-inferiority threshold. All secondary measures confirmed non-inferiority at all assessment points. Improvements made during treatment were maintained through to 12-month follow-up. Participants in each condition reported high levels of satisfaction with the intervention received. Conclusion TCBT is an effective treatment and is not inferior to standard clinic-based CBT, at least in the midterm. This approach provides a means of making a specialized treatment more accessible to many adolescents with OCD. Clinical trial registration information–Evaluation of telephone-administered cognitive-behaviour therapy (CBT) for young people with obsessive-compulsive disorder (OCD); http://www.controlled-trials.com; ISRCTN27070832.

Outcomes of cognitive behaviour therapy for obsessive-compulsive disorder in young people with and without autism spectrum disorders: A case controlled study

Obsessive-compulsive disorder (OCD) and autism spectrum disorders (ASD) are highly co-morbid. It is suggested that youth with ASD will respond less well to cognitive behaviour therapy (CBT), as compared to their typically developing counterparts. To date there is no empirical evidence to support this view. The current study sought to compare CBT for OCD outcomes among youth with and without ASD. 22 young people with ICD-10 diagnoses of OCD and ASD (OCD+ASD) were matched with 22 youth with OCD, but no ASD (OCD+NoASD) according to base line OCD symptom severity, age, and gender. Outcomes were assessed for the two groups following a course of individually tailored, but protocol-driven CBT for OCD. While both groups responded to treatment the OCD+ASD groups outcomes were inferior to the OCD+NoASD group, as indicated by a significantly smaller decrease in symptoms over treatment (38.31% vs. 48.20%) and lower remission rates at post-treatment (9% vs. 46%). Overall, young people experiencing OCD in the context of ASD benefitted from CBT, but to a lesser extent than typically developing children. Recent efforts to modifying standard CBT protocols for OCD in ASD should continue in order to optimise outcomes among youth with this particular dual psychopathology.

Temper outbursts in paediatric obsessive-compulsive disorder and their association with depressed mood and treatment outcome

Background: Temper outbursts in youth with obsessive-compulsive disorder (OCD) are a common source of concern, but remain poorly understood. This study examined a set of hypotheses related to: (a) the prevalence of temper outbursts in paediatric OCD, (b) the associations of temper outbursts with OCD severity and depressive symptoms; and (c) the influence of temper outbursts on treatment response. Methods: The prevalence of temper outbursts was estimated in a specialist OCD clinical sample (n = 387) using parent- and child-report. This was replicated in a community sample (n = 18,415). Associations of temper outbursts with obsessive-compulsive symptoms and with depressed mood were examined using logistic regression models. The influence of temper outbursts on treatment response was examined in a subsample of 109 patients treated with cognitive behaviour therapy (CBT) with or without medication. Results: Over a third of young people with OCD displayed temper outbursts, and rates were similar across the clinical and community samples. Temper outbursts were two to three times more common in youth with OCD than in healthy controls. However, OCD symptom severity was not a strong predictor of child- or parent-reported temper outbursts. Instead, both child- and parent- reported temper outbursts were significantly associated to depressive symptoms. CBT strongly reduced OCD and depressive symptoms, as well as the severity of temper outbursts. There was no significant difference in post-treatment OCD or depression scores between those with temper outbursts compared to those without. Conclusions: Temper outbursts are common in youth with OCD and are particularly related to depressed mood. They improve with CBT for OCD and do not seem to impede OCD treatment response.

Obsessive-compulsive disorder in children and adolescents

Obsessive-compulsive disorder (OCD) in childhood and adolescence is an impairing condition, associated with a specific set of distressing symptoms incorporating repetitive, intrusive thoughts (obsessions) and distressing, time-consuming rituals (compulsions). This review considers current knowledge of causes and mechanisms underlying OCD, as well as assessment and treatment. Issues relating to differential diagnosis are summarised, including the challenges of distinguishing OCD from autism spectrum disorders and tic disorders in youth. The recommended treatments, namely cognitive behaviour therapy and serotonin reuptake inhibiting/selective serotonin reuptake inhibitor medications, are outlined along with the existing evidence-based and factors associated with treatment resistance. Finally, novel clinical developments that are emerging in the field and future directions for research are discussed.

A Pilot Randomized Controlled Trial of Cognitive-Behavioral Therapy for Adolescents With Body Dysmorphic Disorder

OBJECTIVE Body dysmorphic disorder (BDD) typically starts in adolescence, but evidence-based treatments are yet to be developed and formally evaluated in this age group. We designed an age-appropriate cognitive-behavioral therapy (CBT) protocol for adolescents with BDD and evaluated its acceptability and efficacy in a pilot randomized controlled trial. METHOD Thirty adolescents aged 12 to 18 years (mean = 16.0, SD = 1.7) with a primary diagnosis of BDD, together with their families, were randomly assigned to 14 sessions of CBT delivered over 4 months or a control condition of equivalent duration, consisting of written psycho-education materials and weekly telephone monitoring. Blinded evaluators assessed participants at baseline, midtreatment, posttreatment, and at 2-month follow-up. The primary outcome measure was the Yale-Brown Obsessive-Compulsive Scale Modified for BDD, Adolescent Version (mean baseline score = 37.13, SD = 4.98, range = 24-43). RESULTS The CBT group showed a significantly greater improvement than the control group, both at posttreatment (time × group interaction coefficient [95% CI] = -11.26 [-17.22 to -5.31]; p = .000) and at 2-month follow-up (time × group interaction coefficient [95% CI] = -9.62 [-15.74 to -3.51]; p = .002). Six participants (40%) in the CBT group and 1 participant (6.7%) in the control condition were classified as responders at both time points (χ(2) = 4.658, p = .031). Improvements were also seen on secondary measures, including insight, depression, and quality of life at posttreatment. Both patients and their families deemed the treatment as highly acceptable. CONCLUSION Developmentally tailored CBT is a promising intervention for young people with BDD, although there is significant room for improvement. Further clinical trials incorporating lessons learned in this pilot study and comparing CBT and pharmacological therapies, as well as their combination, are warranted. CLINICAL TRIAL REGISTRATION INFORMATION Cognitive-Behaviour Therapy for Adolescents With Body Dysmorphic Disorder; http://www.isrctn.com/; ISRCTN67699666.