Gregory S. Chasson

Treatment Outcome for Adolescent Obsessive-Compulsive Disorder in a Specialized Hospital Setting

Although few data are available concerning adolescents with obsessive-compulsive disorder (OCD), the existing literature suggests that cognitive-behavioral therapy (CBT) is the first-line treatment of choice for adolescents with mild to moderate OCD. A combination of CBT and serotonin reuptake inhibitors (SRIs) is recommended for more severe forms of OCD, based on the Expert Consensus Guidelines for the Treatment of Obsessive-Compulsive Disorder and the Pediatric OCD Treatment Study (POTS). Despite the effectiveness of CBT, a recent meta-analysis found that 27% of adolescent outpatients fail to show clinically significant improvement following CBT and many also fail to show improvement with pharmacotherapy. One alternative for those who do not improve with outpatient treatment is an intensive inpatient program. Within the last 10 years, two specialty hospitals have created programs that provide intensive CBT milieu treatment with multidisciplinary support (e.g., nursing, psychopharmacology) to treat adolescents with OCD. This naturalistic study describes treatment outcomes in 23 patients who received treatment in one of these programs between 2005 and 2006. Results suggest significant improvements on the majority of outcome measures, with 70% of the patients judged to meet criteria for clinically significant change. Thus, inpatient treatment appears potentially efficacious, although future controlled trials with larger samples are needed.

Childhood maltreatment and intimate partner violence in dissociative disorder patients

Background Childhood maltreatment (CM) is a risk factor for subsequent intimate partner violence (IPV) in adulthood, with high rates of retrospectively reported CM among IPV victims and perpetrators. A theorized mechanism of the link between CM and IPV is dissociation. Dissociation may allow perpetrators of violence to remain emotionally distant from their behavior and minimize empathy toward those they victimize, enabling them to commit acts of violence similar to their own experiences. Indeed, elevated rates of dissociation and dissociative disorders (DD) have been found among IPV survivors and perpetrators. In addition, in pilot studies, DD clinicians have reported high levels of violent behavior among DD patients. Objective The present study investigates IPV among DD patients with Dissociative Identity Disorder and Dissociative Disorder Not Otherwise Specified, a group with CM rates of 80–95% and severe dissociative symptoms. Methods DD clinicians reported on rates of CM and IPV among 275 DD patients in outpatient treatment. DD patients also completed a self-report measure of dissociation. Analyses assessed the associations between CM typologies and IPV, as well as trait dissociation and IPV. Results Physical and emotional child abuse were associated with physical IPV, and childhood witnessing of domestic violence (DV) and childhood neglect were associated with emotional IPV. Conclusions The present study is the first to provide empirical support for a possible CM to adult IPV developmental trajectory among DD patients. Future research is needed to better understand the link between CM and IPV among those with trauma and DD.

Perfectionism dimensions as predictors of symptom dimensions of obsessive-compulsive disorder

The correlation between obsessive-compulsive disorder (OCD) and perfectionism is well documented, yet it remains unclear if dimensions of perfectionism vary as a function of OCD symptom dimensions. To this end, the present study investigated the unique associations between dimensions of perfectionism (i.e., concern over mistakes, doubts about actions, personal standards, parental criticism, parental expectations, and organization) and OCD symptom dimensions (i.e., hoarding, washing, checking, ordering, obsessing, and neutralizing). The study included adult patients with OCD (N = 46) from a residential OCD treatment program. Consistent with previous research, doubts about actions was a significant predictor of overall OCD severity and OCD checking symptoms. The organization dimension of perfectionism was a significant predictor of OCD ordering symptoms. The current study provides evidence for the unique relationships between OCD symptoms and perfectionism dimensions that encourage a movement toward greater phenotypic specificity within existing models of OCD.

Obsessive-compulsive personality traits: how are they related to OCD severity?

Previous research has demonstrated that comorbid obsessive-compulsive personality disorder (OCPD) in patients with obsessive-compulsive disorder (OCD) is associated with greater overall OCD severity, functional impairment, and poorer treatment outcomes (Coles et al., 2008; Lochner et al., 2010; Pinto, 2009). However, research has only examined the effects of OCPD categorically and has yet to thoroughly examine the impact of individual OCPD characteristics dimensionally. Thus, the present study sought to investigate the relationships between various OCPD-related dimensions (e.g., perfectionism, rigidity) and OCD symptomology and severity. The study recruited a sample of OCD patients (n=51) in the OCD units of two residential treatment facilities. Findings yielded significant relationships between OCD severity and the following OCPD dimensions: flexibility, doubts about actions (a dimension of perfectionism), and hoarding. Interpretations of these results and the implications for diagnosis, prognosis, and treatment outcome are discussed. Furthermore, the current study provides insight into a unique perspective which leaves room for more symptom overlap and variability between OCD and OCPD.

Shared social competence impairment: another link between the obsessive-compulsive and autism spectrums?

Recently, there has been a growing interest in the phenotypic, pathogenic, and pathophysiological overlap between autism spectrum disorders (ASD) and obsessive-compulsive spectrum disorders (OCSD). However, social competence impairment is one domain of overlap that has received less attention. Codified as one of three diagnostic categories in ASD, pathological social processing has also been demonstrated in OCSD. Yet, to date no reviews have synthesized the research literature on social competence impairments in OCSD, especially impairments that may parallel those found in ASD. The current review set out to examine the extant literature in this area in the service of advancing understanding of shared phenomenology between these two spectrums of conditions. Further, delineation of shared social competence impairments between ASD and OCSD might highlight candidate endophenotypes for further investigation. Ultimately, understanding the links between OCSD and ASD may aid in development of better intervention and prevention strategies, some of which may directly target maladaptive social processing.

Distinguishing simulated from genuine dissociative identity disorder on the MMPI-2.

Due to high elevations on validity and clinical scales on personality and forensic measures, it is challenging to determine if individuals presenting with symptoms of dissociative identity disorder (DID) are genuine or not. Little research has focused on malingering DID, or on the broader issue of the profiles these patients obtain on the Minnesota Multiphasic Personality Inventory (MMPI-2), despite increasing awareness of dissociation. This study sought to characterize the MMPI-2 profiles of DID patients and to determine the utility of the MMPI-2 in distinguishing DID patients from uncoached and coached DID simulators. The analyses revealed that Infrequency, Back Infrequency, and Infrequency-Psychopathology (Fp) distinguished simulators from genuine DID patients. Fp was best able to discriminate simulated DID. Utility statistics and classification functions are provided for classifying individual profiles as indicative of genuine or simulated DID. Despite exposure to information about DID, the simulators were not able to accurately feign DID, which is inconsistent with the iatrogenic/sociocultural model of DID. Given that dissociation was strongly associated with elevations in validity, as well as clinical scales, including Scale 8 (i.e., Schizophrenia), considerable caution should be used in interpreting validity scales as indicative of feigning, and Scale 8 as indicative of schizophrenia, among highly dissociative individuals.

A cross-sectional cohort study of a large, statewide Medicaid home and community-based services autism waiver program.

State-specific 1915(c) Medicaid Home and Community-Based Services waiver programs have become central in the provision of services specifically tailored to children with autism spectrum disorders (ASD). Using propensity score matching, 130 families receiving waiver services for a child with ASD were matched with and compared to 130 families waiting on the registry (i.e., control group). Results indicate that participants in the waiver group reported more improvement in independent living skills and family quality of life over the last year compared to those on the registry. More frequent intensive individual support services and therapeutic integration were statistically predictive of improvement in a variety of domains. The results suggest that the waiver program may be promising for improving child and family functioning.

Dissociative, depressive, and PTSD symptom severity as correlates of nonsuicidal self-injury and suicidality in dissociative disorder patients.

ABSTRACT The present study investigates whether symptom severity can distinguish patients diagnosed with dissociative identity disorder and dissociative disorder not otherwise specified with a recent history of nonsuicidal self-injury (NSSI) and suicide attempts from those patients without recent self-harm. A total of 241 clinicians reported on recent history of patient NSSI and suicide attempts. Of these clinicians’ patients, 221 completed dissociative, depressive, and posttraumatic stress disorder symptomatology measures. Baseline cross-sectional data from a naturalistic and prospective study of dissociative disorder patients receiving community treatment were utilized. Analyses evaluated dissociative, depressive, and posttraumatic stress disorder symptom severity as methods of classifying patients into NSSI and suicide attempt groupings. Results indicated that dissociation severity accurately classified patients into NSSI and suicidality groups, whereas depression severity accurately classified patients into NSSI groups. These findings point to dissociation and depression severity as important correlates of NSSI and suicidality in patients with dissociative disorders and have implications for self-harm prevention and treatment.

A consideration of hoarding disorder symptoms in China

BACKGROUND Hoarding disorder is rarely examined in populations of non-European and/or non-Euro-American descent, especially in East Asian nations like China. Across two studies, the current investigation sets out to examine the psychometric properties of a Chinese version of a widely used measure of hoarding symptoms-the Savings Inventory Revised (SIR)-and to explore the nature of hoarding beliefs compared to a separate US sample. PROCEDURES For the first study, 1828 college students in China completed a Mandarin translation of the SIR and measures of anxiety, depression, and obsessive-compulsive disorder. For the second study, 303 students from China and 87 students from the US completed the SIR and a novel hoarding beliefs questionnaire. FINDINGS In the first study, the Chinese-version of the SIR demonstrated convergent and discriminant validity, as well as internal reliability and preliminary construct validity. However, evidence of temporal stability was modest and requires further investigation. In the second study, the Chinese sample endorsed greater hoarding symptoms and hoarding beliefs compared to the US sample, although only themes of usefulness and wastefulness were associated with hoarding in the Chinese samples, whereas a wider range of beliefs was linked with hoarding in the US sample. In addition, the factor structure of the SIR from the first study did not replicate in second study, suggesting that construct validity of the Chinese SIR may require further corroboration. CONCLUSIONS The current study established preliminary evidence for the reliability and validity of the Chinese SIR, although future research is needed to confirm its temporal stability and factor structure. Hoarding beliefs in China may be centered on themes of usefulness and wastefulness compared to more heterogeneous themes in the West, suggesting differential manifestations of hoarding tendencies in cultures of non-European and/or non-Euro-American descent.

Outcomes of Specialized Residential Treatment for Adults with Obsessive-compulsive Disorder

Cognitive-behavioral therapy (CBT) utilizing exposure and response prevention for obsessive- compulsive disorder (OCD) has typically been studied in the context of time-limited treatment conducted in outpatient settings. However, in practice, patients vary in their response to such treatment, and some require more prolonged participation to obtain optimal benefit. An intensive residential program is one alternative for patients who do not improve in traditional outpatient treatment. This naturalistic study evaluated 46 patients with a primary diagnosis of OCD who received intensive residential treatment between 2004 and 2008. Patients entering the program completed assessments at admission and at discharge. Results indicated statistically significant improvements on all outcome measures, with 60.9% of patients meeting criteria for clinically reliable change in OCD severity and37% achieving high end-state functioning. Specialized residential treatment seems effective for treatment-refractory OCD, although future controlled trials with larger samples are needed. (Journal of Psychiatric Practice 2013;19:429–437)