Gideon E. Anholt

The impact of depression on the treatment of obsessive-compulsive disorder: results from a 5-year follow-up

BACKGROUND Many OCD patients present with comorbid conditions, and major depression is one of the most frequent comorbidities observed. OCD patients with comorbid depression exhibit functional disability and poor quality of life. However, it is unclear whether depressive symptoms are predictive of treatment response, and debate remains whether they should be targeted in the treatment of comorbid patients. The current study aimed at assessing the predictive value of depression and OCD symptoms in the long term outcome of OCD treatment. METHODS In the current study, relations between OCD and depressive symptoms were systematically investigated in a group of 121 OCD patients who received 16 sessions of behavior or cognitive therapy either alone or with fluvoxamine. RESULTS Depression (either as a continuous or categorical variable) was not predictive of treatment response in any of the treatment modalities for up to 5 years of follow-up. Changes in OCD symptoms largely predicted changes in depressive symptoms but not vice versa. LIMITATIONS Subsequent to participation in the RCT, almost two-thirds of the participants received some form of additional treatment (either pharmacological or psychological), and as a result, it is impossible to determine interaction effects with additional treatment received after the trial. CONCLUSIONS Treatment of OCD with comorbid depression should focus on amelioration of OCD symptoms. When OCD treatment is successful, depressive symptoms are likely to ameliorate as well.

Differences between early and late drop-outs from treatment for obsessive-compulsive disorder

To examine characteristics of drop-outs from treatment for obsessive-compulsive disorder (OCD), we studied 121 participants who underwent exposure or cognitive treatment, either alone or with fluvoxamine. OCD symptoms were assessed at pre-treatment, post-treatment, and at every session. No differences in attrition were found between treatment conditions. Drop-outs from treatment (n=31) were divided into early (before session 6) and late (session 6 or after) drop-outs. We found that early drop-outs had more severe OCD symptoms at termination compared to completers, whereas late drop-outs did not differ from treatment completers. Higher levels of depressive symptoms were associated with early drop-outs, and lower levels with completers. These findings suggest that individuals with high levels of pretreatment depression are at risk for early drop-out with elevated OCD symptoms. Conversly, late drop-outs may be treatment responders who drop out after experiencing substantial improvement. Implications for allocation of resources for attrition prevention are discussed.

Did I turn off the stove? Good inhibitory control can protect from influences of repeated checking.

BACKGROUND AND OBJECTIVES Obsessive-compulsive disorder (OCD) is an anxiety disorder characterized by compulsions aimed at reducing anxiety associated with intrusive cognitions. However, compulsive behaviors such as repeated checking were found to increase rather than decrease uncertainty related to obsessive thoughts (e.g., whether the gas stove was turned off). Some recent studies illustrate that OCD patients and their family members have inhibitory deficits, often demonstrated by the stop-signal task. The current study aims to investigate relations between inhibitory control and effects of repeated checking. METHODS Fifty-five healthy participants carried out a stop-signal task followed by a repeated-checking task. Additionally, participants were asked to complete self-report questionnaires measuring OCD, anxiety and depression symptoms. RESULTS Confirming our hypothesis, participants with poor inhibitory capabilities demonstrated greater uncertainty and memory distrust as a consequence of repeated checking than participants with good inhibitory control. LIMITATIONS Our findings concern an initial investigation on a sample of healthy participants and should be replicated and extended to clinical populations. CONCLUSIONS These results suggest that deficits in inhibitory control may underlie cognitive vulnerability in OCD. An updated model integrating neuropsychological findings with current OCD models is suggested.

Always on guard: Test of high vs. low control conditions in obsessive-compulsive disorder patients

Obsessive-compulsive disorder (OCD) is a relatively common psychiatric disorder characterized by recurrent obsessive thoughts and/or compulsive behaviors. It has been shown that OCD patients suffer from deficits in executive control. During Stroop task performance, it was found that cognitive control in healthy participants adjusts adaptively - control is reduced when conflict is less likely. Twenty-four individuals meeting criteria for OCD and 27 controls carried out two blocks of a Stroop task; one with high control (a third of the trials were neutral) and one with low control (75% of the trials were neutral). In the healthy control group, results replicated previous findings showing increased interference and decreased facilitation in the low control condition compared to the high control condition. OCD participants, on the other hand, showed no difference in results between the two blocks. Moreover, in the high control condition, interference was larger and facilitation was smaller compared to healthy controls, indicating less efficient executive control for both the informational and task conflict. We concluded that healthy controls adjust the level of control to changing circumstances whereas OCD patients have difficulties to adaptively make such adjustments. Implications for this novel evidence of deficient executive control of flexibility in OCD patients are discussed.

Examining determinants of early and late age at onset in panic disorder: An admixture analysis

Past research demonstrated that age at onset might account for different clinical and etiological characteristics in panic disorder (PD). However, prior research relied on arbitrary choices of age cut-offs. Using a data-driven validated method, this study aimed to examine differences between early and late onset PD in various determinants. Admixture analysis was used to determine the best fitting model of age at onset distribution in PD. Data was collected from 511 individuals (ages 18-65) with PD diagnoses, who participated in the Netherlands Study of Depression and Anxiety (NESDA). DSM-IV comorbidities and various measures of childhood adversities, suicidal behavior, anxiety and depressive symptoms were assessed. The best fitting cut-off score between early and late age at onset groups was 27 years (early age at onset ≤ 27 years). Univariate tests showed that participants with early onset PD were younger and more likely to be female. Early onset PD was associated with agoraphobia, higher frequency of childhood trauma and life events, and higher rates of suicide attempts as compared to late onset PD. Multivariate logistic regression analysis demonstrated that only current age, childhood trauma and agoraphobia remained significantly associated with early onset PD. Findings suggest that 27 years marks two onset groups in PD, which are slightly distinct. Early onset PD is independently associated with exposure to childhood trauma and increased avoidance. This highlights the importance of subtyping age of onset in PD. Clinical implications are further discussed.

Haven't we met somewhere before? The effects of a brief internet introduction on social anxiety in a subsequent face to face interaction ☆

Social anxiety occurs in a range of social situations, the salience of which is influenced by prevailing modes of social contact. The emergence of computer mediated communication (CMC), buoyed by the recent explosion of social networks, has changed the way many people make and maintain social contacts. We randomly assigned 30 socially anxious and 30 low social anxiety participants to a brief internet chat introduction or a control internet surfing condition followed by a standardized face to face (FTF) interaction. We hypothesized that for socially anxious participants the chat introduction would reduce anxiety of and preference to avoid the subsequent FTF interaction. Results supported hypotheses for most indices. Findings suggest that, at least for the common situation in which internet chat precedes FTF interaction with the same person, such contact may reduce social anxiety. It is not known whether this decrease would generalize to FTF contact in other contexts. It is suggested that CMC might be construed as a particularly useful form of safety behavior that may help in the allocation of attentional resources to process new information relevant for disconfirmation of negative beliefs maintaining social anxiety. Potential clinical implications are discussed.

The Role of Response Inhibition in Medicated and Unmedicated Obsessive‐Compulsive Disorder Patients: Evidence from the Stop‐Signal Task

Numerous studies have investigated response inhibition (RI) in obsessive‐compulsive disorder (OCD), with many reporting that OCD patients demonstrate deficits in RI as compared to controls. However, reported effect sizes tend to be modest and results have been inconsistent, with some studies finding intact RI in OCD. To date, no study has examined the effect of medications on RI in OCD patients.

An admixture analysis of age of onset in agoraphobia

BACKGROUND Age of onset is an important epidemiological indicator in characterizing disorders׳ subtypes according to demographic, clinical and psychosocial determinants. While investigated in various psychiatric conditions, age of onset and related characteristics in agoraphobia have yet to be examined. In light of the new diagnostic status in the DSM-5 edition of agoraphobia as independent from panic disorder, research on agoraphobia as a stand-alone disorder is needed. METHODS Admixture analysis was used to determine the best-fitting model for the observed ages at onset of 507 agoraphobia patients participating in the Netherlands Study of Depression and Anxiety (age range 18-65). Associations between agoraphobia age of onset and different demographic, clinical and psychosocial determinants were examined using multivariate logistic regression analysis. RESULTS Admixture analyses identified two distributions of age of onset, with 27 as the cutoff age (≤27; early onset, >27; late onset). Early onset agoraphobia was only independently associated with family history of anxiety disorders (p<0.01) LIMITATIONS: Age of onset was assessed retrospectively, and analyses were based on cross-sectional data. CONCLUSION The best distinguishing age of onset cutoff of agoraphobia was found to be 27. Early onset agoraphobia might constitute of a familial subtype. As opposed to other psychiatric disorders, early onset in agoraphobia does not indicate for increased clinical severity and/or disability.

Updating the emotional content of working memory in social anxiety

BACKGROUND AND OBJECTIVES Cognitive accounts suggest that information processing biases have an important role in the etiology and maintenance of social anxiety (SA). Empirical evidence support this notion has been established in variety of cognitive domains. Yet, it is still not known how social anxious individuals process emotional content in working memory (WM). Maladaptive WM updating may influence emotion regulation and anxiety during social situations in SA. Thus, the aim of the present study was to explore biases when updating emotional content in SA. METHODS 31 participants with high SA and 34 control participants performed an emotional 2-back task. Biases were assessed by intrusion cost in reaction times, which reflects the conflict between the inhibition of irrelevant content and the activation of relevant content. RESULTS Results revealed a diminished intrusion cost in reaction times for irrelevant positive content in the high, but not in the low SA group. No differences were found for negative or neutral content. LIMITATIONS In the present study we used an analogue sample of students with high SA rather than a true clinical sample. Further research is needed to examine WM updating in clinical population. CONCLUSIONS These findings suggest that individuals with SA are better at inhibiting irrelevant positive information, a maladaptive cognitive bias that may prevent positive feedback from entering the cognitive system. This cognitive bias in WM may play a role in the etiology and maintenance of SA.

Stop checking: Repeated checking and its effects on response inhibition and doubt.

BACKGROUND Repeated checking is a common ritual in obsessive-compulsive disorder (OCD). van den Hout and Kindt (2003b) devised a task demonstrating paradoxical reductions in memory confidence following repeated checking. This effect was later found to be contingent upon response inhibition. The current study aims to (1) test an alternative interpretation, whereby repeated-checking effects are caused by viewing multiple exemplars, and (2) test whether repeated checking affects response inhibition. METHOD 132 students participated in two experiments (66 in Experiment 1 and 66 in Experiment 2). Participants were randomly allocated to a repeated-checking task or a simple-action task that featured similar multiple exemplars without the need for checking. Both tasks were followed by a stop-signal task, measuring response inhibition. Experiment 1 featured a stop-signal task with neutral go-signals while Experiment 2 incorporated familiar and unfamiliar stimuli from the previous task as go-signals. RESULTS In both experiments, the repeated-checking group exhibited reduced memory confidence compared to the simple-action group. Groups did not differ in their response inhibition for neutral stimuli (Experiment 1), while familiar go-signals had a detrimental effect on response inhibition (Experiment 2). LIMITATIONS Our results examine the association between checking and response inhibition in healthy participants without attention deficit hyperactivity disorder and dyslexia. Replication with clinical samples awaits future studies. CONCLUSIONS Repeated checking impairs memory confidence. Increased familiarity of stimuli shortens the time it takes to respond to them while it impairs inhibition response to them. These effects possibly provide initial evidence for the hypothesized role of response inhibition in the maintenance of OCD.