Michael J. Kozak

Emotional processing of fear: exposure to corrective information.

In this article we propose mechanisms that govern the processing of emotional information, particularly those involved in fear reduction. Emotions are viewed as represented by information structures in memory, and anxiety is thought to occur when an information structure that serves as program to escape or avoid danger is activated. Emotional processing is denned as the modification of memory structures that underlie emotions. It is argued that some form of exposure to feared situations is common to many psychotherapies for anxiety, and that confrontation with feared objects or situations is an effective treatment. Physiological activation and habituation within and across exposure sessions are cited as indicators of emotional processing, and variables that influence activation and habituation of fear responses are examined. These variables and the indicators are analyzed to yield an account of what information must be integrated for emotional processing of a fear structure. The elements of such a structure are viewed as cognitive representations of the stimulus characteristic of the fear situation, the individuals responses in it, and aspects of its meaning for the individual. Treatment failures are interpreted with respect to the interference of cognitive defenses, autonomic arousal, mood state, and erroneous ideation with reformation of targeted fear structures. Applications of the concepts advanced here to therapeutic practice and to the broader study of psychopathology are discussed.

Cognitive‐Behavioral Treatment of Pediatric Obsessive‐Compulsive Disorder: An Open Clinical Trial

OBJECTIVE The purpose of this open clinical trial was to examine the efficacy of cognitive-behavioral treatment involving exposure and ritual prevention for pediatric obsessive-compulsive disorder (OCD). METHOD Children and adolescents with diagnosed OCD (N = 14) received cognitive-behavioral treatment, seven patients received intensive treatment (mean = 18 sessions over 1 month) and seven received weekly treatment (mean = 16 sessions over 4 months). Eight of these patients received concurrent treatment with serotonin reuptake inhibitors and six received cognitive-behavioral treatment alone. Outcome was assessed via interviewer ratings on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), Obsessive Compulsive Rating Scales for Main Fear and Main Ritual, and Hamilton Depression Rating Scale. RESULTS Cognitive-behavioral treatment was effective in ameliorating OCD symptoms. Twelve of the 14 patients were at least 50% improved over pretreatment Y-BOCS severity, and the vast majority remained improved at follow-up; mean reduction in Y-BOCS was 67% at posttreatment and 62% at follow-up (mean time to follow-up = 9 months). CONCLUSIONS Results suggest that cognitive-behavioral treatment by exposure and ritual prevention is effective for pediatric OCD. Controlled studies with random assignment to conditions are warranted to evaluate the relative efficacy of cognitive-behavioral pharmacological, and combined treatments.

Process and outcome of exposure treatment with obsessive-compulsives: Psychophysiological indicators of emotional processing

Three indicators of emotional processing — peak response, habituation within sessions, and habituation across sessions — were examined in relation to therapy outcome with 14 obsessive-compulsives who were treated by 15 sessions of exposure in imagination and in vivo. Treatment outcome was evaluated by therapist, independent assessor, and self-ratings of target symptoms. Processes during therapy were assessed via self-report of anxiety as well as cardiac and electrodermal responses recorded during treatment sessions 6 and 14. Overall, the treatment was successful. As hypothesized, fear activation during exposure and habituation within sessions were evident in both self-report and physiological measures; habituation across sessions was observed in group means only for self-report. Also as hypothesized, both fear activation during exposure and greater habituation across sessions predicted better posttreatment ratings of obsessional fear. Habituation within sessions did not predict individual differences in outcome. These results support the theoretical formulation developed by Foa and Kozak (1986) to explain the effects of exposure therapy.

Effects of comorbid Depression on response to treatment for obsessive-compulsive disorder

We examined the effects of comorbid depression on response to treatment for obsessive-compulsive disorder (OCD) using cognitive-behavioral therapy with and without medication. Eighty-seven OCD patients were divided into nondepressed and mildly, moderately, and severely depressed groups on the basis of their pretreatment Beck Depression Inventory (BDI) scores. Each received an intensive cognitive-behavioral treatment program involving exposure with response prevention (EX/RP); 59 (68%) were also taking medication for OCD. Patients with severe initial depression (BDI ≥30) showed significantly less improvement compared to those less depressed or nondepressed; yet, even highly depressed patients showed moderate treatment gains. Failure to habituate to anxiety-evoking stimuli during exposure and a lack of motivation for therapy are considered possible causes of attenuated outcome.

Fixity of belief, perceptual aberration, and magical ideation in obsessive-compulsive disorder.

Clinicians and researchers have pondered the intersection of obsessive-compulsive disorder (OCD) and psychosis. We examined the records of 395 individuals seeking treatment for OCD and classified participants according to their most frequent or distressing obsession and compulsion. All participants completed measures of fixity of belief, perceptual distortions, magical ideation, and psychotic symptoms. Results indicated that individuals who reported fear of harming self or others via overwhelming impulse or by mistake, and those with religious obsessions, had poorer insight and more perceptual distortions and magical ideation than did individuals with other types of obsessions. These results did not appear to reflect mere differences in OCD severity. Results are discussed in light of previous findings showing that psychotic-like symptoms are associated with attenuated treatment outcome in OCD. More research is needed to assess the absolute magnitude of psychotic-like features in OCD patients with impulse/mistake and religious obsessions and to examine whether these features interfere with standard cognitive-behavioral therapy.

Posttraumatic stress disorder in rape victims: autonomic habituation to auditory stimuli.

Impaired capacity for physiological habituation may contribute to the persistence of PTSD. Habituation of autonomic responses to auditory tones was examined in 43 women in three groups: 14 adult female rape survivors with chronic PTSD, 11 without PTSD, and a comparison group of 18 who had not been raped. There were no significant differences among the groups in baseline cardiac or electrodermal activity. The PTSD group showed significantly slower electrodermal habituation, as measured by trials to extinction and percentage of nonhabituators, than did the comparison groups. The present study found slower habituation of electrodermal responses for PTSD rape victims to neutral stimuli than for non-PTSD victims and nonvictims.

Clinical applications of bioinformational theory : Understanding anxiety and its treatment

This paper considers the clinical applications of the bioinformational theory of emotion developed by Peter Lang and his colleagues over the past 30 years. Three aspects of this body of work are discussed: the conceptual framework, the methods that were developed to examine the theoretical concepts, and the empirical data that were derived from these methods. The myriad contributions of bioinformational theory to three areas of clinical application are reviewed: assessment, diagnosis, and treatment. It is concluded that bioinformational theory has furthered our understanding of emotion, especially anxiety, and that the theorys recent developments in the area of basic neurophysiological substrata of affect hold promise for continued clinical application.

Long-term efficacy of exposure and ritual prevention therapy and serotonergic medications for obsessive-compulsive disorder.

What is the long-term outcome of patients with obsessive-compulsive disorder (OCD) who are treated with exposure and response (ritual) prevention (EX/RP) alone, serotonergic medications alone, or their combination? How is the long-term outcome of these patients affected by the discontinuation? Follow-up assessments were conducted with 62 patients treated for OCD an average of 17 months posttreatment (range: 6-43 months). Patients received one of three treatments: serotonergic medications (fluvoxamine or clomipramine), intensive behavior therapy involving EX/RP, or intensive EX/RP with concurrent antidepressant medication. At follow-up, no differences in OCD symptom severity were found among the three treatment groups. However, when current medication use was taken into consideration, differences among the three treatment groups emerged. Among patients who were medication-free at the time of follow-up assessment (n=37), those in the EX/RP-alone and EX/RP-with-medication groups had lower symptom severity ratings than those in the medication-only group on 4 out of 6 measures. There were no differences in OCD severity ratings among patients taking medications at follow-up (n=25). Although these findings are interpreted with caution due to the uncontrolled nature of the study, results suggested that long-term outcome may be superior following EX/RP than following serotonergic medications, after discontinuation. For patients who remain on medications, the treatment produced benefits equivalent to EX/RP.

Beyond the efficacy ceiling? Cognitive behavior therapy in search of theory *

The enterprise of behavior therapy began with enormous optimism that was reinforced by early clinical impressions. As the field developed, there has been a growing recognition that the efficacy of behavior therapy is limited, as many patients do not improve and some do not maintain their gains. In this paper we take a historical view of behavior therapy with a focus on the limits of its efficacy and on the influence of experimental psychology on its development. We have considered several possible explanations for the findings indicating limited success of behavior therapies. We suggest that the advance of cognitive behavior therapy may be slowed, in part, by alienation from experimental psychology and psychopathology research.

Effects of imipramine on depression and obsessive-compulsive symptoms

Most of the controlled studies on the efficacy of medical treatments of obsessive-compulsive disorder (OCD) have involved clomipramine, a tricyclic antidepressant reputed to have anti-obsessional properties. To test the possibility that the drugs antidepressant action mediates the reduction of obsessive-compulsive symptoms, we treated 37 OCD patients with imipramine (mean dose = 233 mg/day) or placebo for 6 weeks and assessed improvement on both obsessive-compulsive and depressive symptoms. Imipramine reduced depression in highly depressed OCD patients, but did not affect obsessive-compulsive symptoms in these or in less depressed patients.