Kieron O’Connor

The Impact of DSM-IV Symptom and Clinical Significance Criteria on the Prevalence Estimates of Subthreshold and Threshold Anxiety in the Older Adult Population

OBJECTIVES Subthreshold anxiety refers to a condition where individuals do not meet the full symptom criteria (i.e., the number of symptoms required for a formal diagnosis is not reached) and/or do not report significant impairment or distress in functioning (i.e., the clinical significance criterion is not met). The purpose of this study was to examine how the symptom and the clinical significance criteria may affect the prevalence estimates of anxiety problems in the older adult population and whether applying these criteria results in an identifiable older group showing more severe anxiety. SETTING AND PARTICIPANTS Data came from a large representative sample of community-dwelling older adults age 65 years and older (N = 2,784). RESULTS Results showed that the 12-month prevalence rate of any anxiety problem varied from 5.6% when DSM-IV criteria for anxiety disorders were used to 26.2% when all subthreshold manifestations of anxiety were considered. Findings also indicated that when compared with respondents without anxiety, older adults presenting different manifestations of subthreshold or threshold anxiety appear to be more similar than different in their health and health behavior characteristics. CONCLUSIONS Subthreshold anxiety has a high prevalence and may cause significant impairment. Both symptom and clinical significance criteria do not perfectly discriminate between older adults with or without a severe anxiety problem presenting comorbid disorders and needing psychiatric help.

Specificity of belief domains in OCD: Validation of the French version of the Obsessive Beliefs Questionnaire and a comparison across samples

This paper assesses the psychometric properties of the French version of the Obsessive Beliefs Questionnaire (OBQ-44) and investigates whether the questionnaire discriminates between obsessive-compulsive disorder (OCD), anxious control (AC), and non-clinical control (NCC) participants. A confirmatory factor analysis suggested a poor fit of the model. An exploratory factor analysis replicated the original factor structure. The subscales were moderately intercorrelated and highly correlated with the total score. There was partial support for convergent/divergent validity of the OBQ-44. In analyses of variance comparing the three samples, the participants in the OCD sample scored significantly higher than the participants in the AC and NCC samples on all of the OBQ-44 scores. In analyses of covariance comparing the OCD and NCC samples while controlling for general distress and age, the participants with OCD scored significantly higher than the NCC participants on all of the OBQ-44 scores. Implications of the current study are discussed.

Inferential confusion, obsessive beliefs, and obsessive-compulsive symptoms: A replication and extension

This study replicated and extended previous research regarding utility of an inference-based approach (IBA) to the study of Obsessive-Compulsive Disorder (OCD). The IBA is a model for the development of OCD symptoms through false reasoning. One of its key features is inferential confusion-a form of processing information in which an individual accepts a remote possibility based only on subjective evidence. In a nonclinical sample, this study examined the specificity of relations between the expanded Inferential Confusion Questionnaire (ICQ-EV) and OC symptoms. Results were that the ICQ-EV significantly predicted OC symptoms after controlling for general distress, anxiety, and depression. This finding supports the unique association between inferential confusion and OCD. Further, the ICQ-EV was a stronger predictor of certain OC symptoms than scales from the Obsessive Beliefs Questionnaire, which itself has shown strong relations with OC symptoms. Thus, both inference-based and cognitive appraisal models appear useful for understanding OCD.

Prevalence and correlates of obsessive-compulsive disorder among older adults living in the community

The purpose of this study was to determine OCD prevalence among older adults living in the community and to examine its correlates. Data were drawn from a large population survey using a representative sample of older adults aged 65 years and over (N=2798). The 12-month prevalence rate of OCD was 1.5%. Results showed that older adults with OCD were more likely to be men compared to those having another anxiety disorder or a mood disorder. They were also more afflicted with difficulties in social functioning than respondents presenting another anxiety disorder. In spite of social disabilities, respondents with OCD had the lowest rate of health services use among those reporting anxiety or mood disorders. It is suggested that older adults with OCD did not feel the need to seek treatment because they perceived their physical and mental health more positively than others and because they were surrounded by supportive peers.

Cognitive-Behavioral Treatment of Trichotillomania, Targeting Perfectionism

Trichotillomania or hair pulling has been considered mainly as a tensionreducing habit. However, other cognitive, emotional, and situational factors have been identified as important in the development andmaintenance of this disorder. The present case study applied habit reversal techniques, with the addition of a cognitive modification of perfectionist beliefs and style of action, in the treatment of a 23-year-old woman. During an 18-week period, her hair-pulling behavior decreased from a mean of 24 hairs pulled each day to 1 hair pulled overall in a week. A 1.5-year follow-up showed that the client suffered a small relapse during a period of 2 weeks. A self-imposed return to cognitive and behavioral techniques eliminated further pulling. This single case report raises the possibility that perfectionismmay be an important target for cognitive-behavioral treatment intervention in habit disorders such as trichotillomania.

Musical obsessions: a comprehensive review of neglected clinical phenomena.

Intrusive musical imagery (IMI) consists of involuntarily recalled, short, looping fragments of melodies. Musical obsessions are distressing, impairing forms of IMI that merit investigation in their own right and, more generally, research into these phenomena may broaden our understanding of obsessive-compulsive disorder (OCD), which is phenomenologically and etiologically heterogeneous. We present the first comprehensive review of musical obsessions, based on the largest set of case descriptions ever assembled (N=96). Characteristics of musical obsessions are described and compared with normal IMI, musical hallucinations, and visual obsessional imagery. Assessment, differential diagnosis, comorbidity, etiologic hypotheses, and treatments are described. Musical obsessions may be under-diagnosed because they are not adequately assessed by current measures of OCD. Musical obsessions have been misdiagnosed as psychotic phenomena, which has led to ineffective treatment. Accurate diagnosis is important for appropriate treatment. Musical obsessions may respond to treatments that are not recommended for prototypic OCD symptoms.

The inference-based approach to obsessive-compulsive disorder: A comprehensive review of its etiological model, treatment efficacy, and model of change

BACKGROUND The inference-based approach (IBA) postulates that individuals with obsessive-compulsive disorder (OCD) confuse a possibility with reality (inferential confusion) according to specific inductive reasoning devices and act as if this possibility were true. A new treatment modality, the inference-based therapy (IBT), was developed. The aim of this study was to critically review empirical evidence regarding the etiological model, treatment efficacy, and model of change of IBA. METHODS A search of the literature was conducted using PsycINFO and Medline. RESULTS Thirty-four articles were included in the review. The review reveals that intrusive thoughts of non-clinical and OCD individuals may occur in different contexts. There is support for a specific inductive reasoning style in OCD. Inferential confusion is associated with OCD symptoms. There is good evidence that IBT is an efficacious treatment for OCD, including two randomized controlled trials showing that IBT was as efficacious as cognitive-behavior therapy. There is some but limited evidence that the process of change during treatment is coherent with IBAs assumptions. LIMITATIONS Key premises were investigated in only a few studies. Some of these studies were conducted in non-clinical samples or did not include an anxious control group. CONCLUSIONS IBAs etiological model, treatment modality, and model of change make a significant contribution to OCD.

The Inference-Based Approach (IBA) to the Treatment of Obsessive–Compulsive Disorder: An Open Trial Across Symptom Subtypes and Treatment-Resistant Cases

The current open trial evaluated an inference-based approach (IBA) to the treatment of obsessive-compulsive disorder (OCD) across symptom subtypes and treatment-resistant cases. Following formal diagnosis through semi-structured interview by an independent evaluator, a total of 125 OCD participants across five major symptom subtypes entered a program of 24 sessions of treatment based on the IBA. An additional group of 22 participants acted as a natural wait-list control group. Participants were administered the Yale-Brown Obsessive-Compulsive Scale before and after treatment as the principal outcome measure, as well as measures of negative mood states, inferential confusion and obsessive beliefs. Level of overvalued ideation was assessed clinically at pre-treatment using the Overvalued Ideation Scale. After 24 weeks of treatment, 102 treatment completers across all major subtypes of OCD showed significant reductions on the Yale-Brown Obsessive-Compulsive Scale with effect sizes ranging from 1.49 to 2.53 with a clinically significant improvement in 59.8% of participants. No improvement was observed in a natural wait-list comparison group. In addition, IBA was effective for those with high levels of overvalued ideation. Change in inferential confusion and beliefs about threat and responsibility were uniquely associated with treatment outcome. The study is the first large-scale open trial showing IBA to be effective across symptom subtypes and treatment-resistant cases. The treatment may be particularly valuable for those who have previously shown an attenuated response to other treatments. Copyright

The Effect of a New Therapy for Children with Tics Targeting Underlying Cognitive, Behavioral, and Physiological Processes

Tourette disorder (TD) is characterized by motor and vocal tics, and children with TD tend to present a lower quality of life than neurotypical children. This study applied a manualized treatment for childhood tics disorder, Facotik, to a consecutive case series of children aged 8–12 years. The Facotik therapy was adapted from the adult cognitive and psychophysiological program validated on a range of subtypes of tics. This approach aims to modify the cognitive–behavioral and physiological processes against which the tic occurs, rather than only addressing the tic behavior. The Facotik therapy lasted 12–14 weeks. Each week 90-min session contained 20 min of parental training. The therapy for children followed 10 stages including: awareness training; improving motor control; modifying style of planning; cognitive and behavioral restructuring; and relapse prevention. Thirteen children were recruited as consecutive referrals from the general population, and seven cases completed therapy and posttreatment measures. Overall results showed a significant decrease in symptom severity as measured by the YGTSS and the TSGS. However, there was a discrepancy between parent and child rating, with some children perceiving an increase in tics, possibly due to improvement of awareness along therapy. They were also individual changes on adaptive aspects of behavior as measured with the BASC-2, and there was variability among children. All children maintained or improved self-esteem posttreatment. The results confirm the conclusion of a previous pilot study, which contributed to the adaptation of the adult therapy. In summary, the Facotik therapy reduced tics in children. These results underline that addressing processes underlying tics may complement approaches that target tics specifically.

The Impact of a Cognitive–Behavioral Therapy on Event-Related Potentials in Patients with Tic Disorders or Body-Focused Repetitive Behaviors

Context Tic disorders (TD) are characterized by the presence of non-voluntary contractions of functionally related groups of skeletal muscles in one or multiple body parts. Patients with body-focused repetitive behaviors (BFRB) present frequent and repetitive behaviors, such as nail biting or hair pulling. TD and BFRB can be treated with a cognitive–behavioral therapy (CBT) that regulates the excessive amount of sensorimotor activation and muscular tension. Our CBT, which is called the cognitive–psychophysiological (CoPs) model, targets motor execution and inhibition, and it was reported to modify brain activity in TD. However, psychophysiological effects of therapy are still poorly understood in TD and BFRB patients. Our goals were to compare the event-related potentials (ERP) of TD and BFRB patients to control participants and to investigate the effects of the CoPs therapy on the P200, N200, and P300 components during a motor and a non-motor oddball task. Method Event-related potential components were compared in 26 TD patients, 27 BFRB patients, and 27 control participants. ERP were obtained from 63 EEG electrodes during two oddball tasks. In the non-motor task, participants had to count rare stimuli. In the motor task, participants had to respond with a left and right button press for rare and frequent stimuli, respectively. ERP measures were recorded before and after therapy in both patient groups. Results CoPs therapy improved symptoms similarly in both clinical groups. Before therapy, TD and BFRB patients had reduced P300 oddball effect during the non-motor task, in comparison with controls participants. An increase in the P300 oddball effect was observed posttherapy. This increase was distributed over the whole cortex in BFRB patients, but localized in the parietal area in TD patients. Discussion These results suggest a modification of neural processes following CoPs therapy in TD and BFRB patients. CoPs therapy seems to impact patients’ attentional processes and context updating capacities in working memory (i.e., P300 component). Our results are consistent with a possible role of the prefrontal cortex and corpus callosum in mediating interhemispheric interference in TD.