Marni L. Jacob

Family Accommodation in Pediatric Obsessive–Compulsive Disorder

Despite the importance of the family in the treatment of pediatric obsessive–compulsive disorder (OCD), relatively little empirical attention has been directed to family accommodation of symptoms. This study examined the relations among family accommodation, OCD symptom severity, functional impairment, and internalizing and externalizing behavior problems in a sample of 57 clinic-referred youth 7 to 17 years old (M = 12.99 ± 2.54) with OCD. Family accommodation was a frequent event across families. Family accommodation was positively related to symptom severity, parent-rated functional impairment (but not child-rated impairment), and externalizing and internalizing behavior problems. Family accommodation mediated the relation between symptom severity and parent-rated functional impairment.

Impact of Comorbidity on Cognitive-Behavioral Therapy Response in Pediatric Obsessive-Compulsive Disorder.

OBJECTIVE To examine the impact of psychiatric comorbidity on cognitive-behavioral therapy response in children and adolescents with obsessive-compulsive disorder. METHOD Ninety-six youths with obsessive-compulsive disorder (range 7-19 years) received 14 sessions of weekly or intensive family-based cognitive-behavioral therapy. Assessments were conducted before and after treatment. Primary outcomes included scores on the Childrens Yale-Brown Obsessive-Compulsive Scale, response rates, and remission status. RESULTS Seventy-four percent of participants met criteria for at least one comorbid diagnosis. In general, participants with one or more comorbid diagnoses had lower treatment response and remission rates relative to those without a comorbid diagnosis. The number of comorbid conditions was negatively related to outcome. The presence of attention-deficit/hyperactivity disorder and disruptive behavior disorders was related to lower treatment response rates, and the presence of disruptive behavior disorders and major depressive disorder were related to lower remission rates. CONCLUSIONS The presence of a comorbid disorder, particularly disruptive behavior, major depressive, and attention-deficit/hyperactivity disorders, has a negative impact on treatment response. Assessing for psychiatric disorders before treatment entry and treating these comorbid conditions before or during cognitive-behavioral therapy may improve final outcome. Comorbid anxiety or tic disorders do not seem to negatively affect response.

D-cycloserine does not enhance exposure-response prevention therapy in obsessive-compulsive disorder

Obsessive–compulsive disorder is a common, chronic, and oftentimes disabling disorder. The only established first-line treatments for obsessive–compulsive disorder are exposure and response prevention therapy and the serotonin reuptake inhibitors. Many patients do not experience complete symptom resolution with either modality and require augmentation approaches. Recent animal and clinical data suggest that D-cycloserine, a partial agonist that acts at the strychnine-insensitive glycine-recognition site of the N-methyl-D-aspartate receptor complex, may enhance extinction learning that occurs in exposure-based psychotherapies. Given this, this study examined if D-cycloserine (250 mg) enhances the overall efficacy and rate of change of exposure and response prevention therapy for adult obsessive–compulsive disorder. Participants were 24 adults meeting Diagnostic and Statistical Manual of Mental Disorders-IV criteria for obsessive–compulsive disorder. The study design was a randomized, double-blinded, placebo-controlled augmentation trial examining exposure and response prevention therapy+D-cycloserine versus exposure and response prevention therapy+placebo. All patients received 12 weekly sessions of exposure and response prevention treatment. The first session involved building a ritual hierarchy and providing psychoeducation about obsessive–compulsive disorder. The second session involved a practice exposure. Sessions 3–12 involved exposure and response prevention exercises. D-cycloserine or placebo (250 mg) was taken 4 h before every session. No significant group differences were found across outcome variables. The rate of improvement did not differ between groups. The present results fail to support the use of D-cycloserine with exposure and response prevention therapy for adult obsessive–compulsive disorder. As this study is the first to explore this question and a number of methodological issues must be considered when interpreting the findings, the conclusions that may be drawn from our results are limited.

Feasibility of Exercise Training for the Short-Term Treatment of Generalized Anxiety Disorder: A Randomized Controlled Trial

Background: Exercise training may be especially helpful for patients with generalized anxiety disorder (GAD). We conducted a randomized controlled trial to quantify the effects of 6 weeks of resistance (RET) or aerobic exercise training (AET) on remission and worry symptoms among sedentary patients with GAD. Methods: Thirty sedentary women aged 18–37 years, diagnosed by clinicians blinded to treatment allocation with a primary DSM-IV diagnosis of GAD and not engaged in any treatment other than pharmacotherapy, were randomly allocated to RET, AET, or a wait list (WL). RET involved 2 weekly sessions of lower-body weightlifting. AET involved 2 weekly sessions of leg cycling matched with RET for body region, positive work, time actively engaged in exercise, and load progression. Remission was measured by the number needed to treat (NNT). Worry symptoms were measured by the Penn State Worry Questionnaire. Results: There were no adverse events. Remission rates were 60%, 40%, and 30% for RET, AET, and WL, respectively. The NNT was 3 (95% CI 2 to 56) for RET and 10 (95% CI –7 to 3) for AET. A significant condition-by-time interaction was found for worry symptoms. A follow-up contrast showed significant reductions in worry symptoms for combined exercise conditions versus the WL. Conclusions: Exercise training, including RET, is a feasible, low-risk treatment that can potentially reduce worry symptoms among GAD patients and may be an effective adjuvant, short-term treatment or augmentation for GAD. Preliminary findings warrant further investigation.

Cognitive behavioral therapy plus motivational interviewing improves outcome for pediatric obsessive-compulsive disorder: a preliminary study.

Abstract Lack of motivation may negatively impact cognitive behavioral therapy (CBT) response for pediatric patients with obsessive–compulsive disorder (OCD). Motivational interviewing is a method for interacting with patients in order to decrease their ambivalence and support their self-efficacy in their efforts at behavior change. The authors present a preliminary randomized trial (N = 16) to evaluate the effectiveness of adding motivational interviewing (MI) as an adjunct to CBT. Patients aged 6 to 17 years who were participating in intensive family-based CBT for OCD were randomized to receive either CBT plus MI or CBT plus extra psychoeducation (PE) sessions. After four sessions, the mean Childrens Yale-Brown Obsessive Compulsive Scale (CY-BOCS) score for the CBT plus MI group was significantly lower than for the CBT plus psychoeducation group, t(14) = 2.51, p < .03, Cohens d = 1.34. In addition, the degree of reduction in CY-BOCS scores was significantly greater, t(14) = 2.14, p = .05, Cohens d = 1.02, for the CBT plus MI group (mean Δ = 16.75, SD = 9.66) than for the CBT plus psychoeducation group (mean Δ = 8.13, SD = 6.01). This effect decreased over time, and scores at posttreatment were not significantly different. However, participants in the MI group completed treatment on average three sessions earlier than those in the psychoeducation group, providing support for the utility of MI in facilitating rapid improvement and minimizing the burden of treatment for families.

Insight in pediatric obsessive-compulsive disorder: Associations with clinical presentation

Insight has emerged as a significant treatment outcome predictor in adult obsessive-compulsive disorder (OCD), with some suggesting that OCD with poor insight represents a distinct clinical subtype. Despite its clinical relevance, limited data exist on insight in pediatric OCD patients. The present study investigated the relation between poor insight and clinical characteristics among children and adolescents with OCD (N=78, ages 6-20 years). Forty-five percent of the sample (n=35) was considered to have low levels of insight into their symptoms, as determined by clinician rating on item 11 of the Childrens Yale-Brown Obsessive-Compulsive Scale. Pearson product-moment correlations showed a significant, inverse relation between insight and OCD severity. Relative to the high insight group, parents of patients with low insight reported higher levels of OCD-related impairment and family accommodation. These findings suggest that OCD with poor insight may represent a distinct clinical feature that may require more intensive and multimodal treatment approaches.

Symptom dimensions and cognitive-behavioural therapy outcome for pediatric obsessive-compulsive disorder.

Objective:  To examine whether obsessive‐compulsive disorder (OCD) symptom subtypes are associated with response rates to cognitive‐behavioural therapy (CBT) among pediatric patients.

Cognitive-behavioral therapy for obsessive–compulsive disorder: A non-randomized comparison of intensive and weekly approaches

This study examined the relative efficacy of intensive versus weekly cognitive-behavioral therapy (CBT) for adults with obsessive-compulsive disorder (OCD). Sixty-two adults with OCD received either 14 sessions of weekly (n=30) or intensive CBT (n=32; daily psychotherapy sessions) in a non-randomized format. Assessments were conducted at Pre-treatment, Post-treatment, and 3-month Follow-up by raters who were blind to treatment group at the Pre-treatment assessment. Intensive and weekly CBT were similar in efficacy at Post-treatment and Follow-up and associated with large treatment effect sizes. Since many people with OCD do not have access to trained CBT providers, intensive treatment may be a viable option in such cases.

Further psychometric analysis of the Florida Obsessive-Compulsive Inventory

This study examined the psychometric properties of the Florida Obsessive-Compulsive Inventory (FOCI [Storch, E. A., Stigge-Kaufman, D., Bagner, D., Merlo, L. J., Shapira, N. A., Geffken, G. R., et al. (2007). Florida Obsessive-Compulsive Scale: development, reliability, and validity. Journal of Clinical Psychology, 63, 851-859]). Participants were 89 adults with OCD presenting for treatment at a specialty clinic. A trained clinician administered the Yale-Brown Obsessive Compulsive Scale and patients completed the FOCI, Obsessive-Compulsive Inventory-Revised, Beck Depression Inventory-Second Edition, and State Trait Anxiety Inventory at baseline and following 14 weekly or daily cognitive behavioral therapy sessions. The internal consistency of FOCI Symptom Checklist and Severity Scale were good, and the concurrent and divergent validity of the FOCI Symptom Checklist and Severity Scale was supported through its associations with clinician-rated OCD symptom severity, and self-reported OCD, depressive, and anxiety measures. In addition, sensitivity to cognitive-behavioral treatment effects was shown as the Severity Scale scores were significantly lower following treatment compared to baseline. These findings not only replicate Storch et al. [Storch, E. A., Stigge-Kaufman, D., Bagner, D., Merlo, L. J., Shapira, N. A., Geffken, G. R., et al. (2007). Florida Obsessive-Compulsive Scale: development, reliability, and validity. Journal of Clinical Psychology, 63, 851-859] but also add unique construct validity data in support of the psychometrics of the FOCI.

Psychosocial Functioning in Youth with Glycogen Storage Disease Type I

OBJECTIVE To assess the quality of life and psychosocial functioning among pediatric patients with Glycogen Storage Disease (GSD) types Ia and Ib. METHODS Thirty-one youth with GSD types Ia and Ib and 42 healthy controls participated. Quality of life ratings from the GSD types Ia and Ib sample were compared with a previously reported clinical comparison sample. Children completed measures of quality of life, loneliness, family functioning, and sibling relationship quality (e.g., warmth, conflict). Parents completed measures of parental distress, parenting stress, child adaptive behavior, and child emotional and behavioral functioning. RESULTS Quality of life was generally lower in youth with GSD relative to healthy controls but similar to those with a chronic illness. Children with GSD were rated as having more internalizing symptoms, social problems, and lower independent functioning relative to healthy controls. Parents reported greater distress and parenting stress relative to healthy controls. CONCLUSIONS The presence of GSD types Ia and Ib are associated with reduced quality of life and independent functioning, and elevated levels of internalizing distress and parental stress relative to healthy peers. Relative to their children, parents generally reported that their child was more impaired, which suggests the need for multiple informants during assessment and active parental involvement during psychological treatment. These points should be kept in mind when assessing and treating youth with this disease and their families as psychological interventions that target areas of concern (e.g., adherence, coping with having a chronic disease) may be helpful for improving child and family outcomes.