Background: Acceptance and commitment therapy (ACT) has been shown to promote willingness to experience intrusive thoughts among individuals with obsessive-compulsive disorder (OCD). Exposure with response prevention (ERP) delivered from an ACT framework (i.e., ACT+ERP) may facilitate changes in how patients relate to their unwanted internal experiences.Aims: Accordingly, the present study aimed to examine the effect of ACT+ERP on appraisals of intrusive thoughts, relative to standard ERP.Methods: Forty-eight adults who received 16 treatment sessions as part of a randomized controlled trial comparing standard ERP to ACT+ERP completed the Interpretation of Intrusions Inventory (III) at pre-treatment, post-treatment, and follow-up.Results: Results showed a significant main effect of time for all III subscales, suggesting that appraisals of intrusive thoughts shift over the course of treatment. The effect of the condition × time interaction, however, differed between the III subscales. Specifically, a significant interaction emerged for the control of thoughts subscale, such that individuals who received ACT+ERP experienced greater reductions in beliefs about the need to control thoughts. The interaction term was not significant for importance of thoughts or responsibility subscales.Conclusions: Findings suggest that augmenting ERP with ACT enhances change in beliefs about the need to control thoughts, but not in beliefs about responsibility and the importance of thoughts. Clinical implications and future research directions will be discussed.

BackgroundA growing body of evidence suggest individuals with obsessive-compulsive disorder (OCD) are at an increased risk for suicidal thoughts and behaviors (SITB). However, the literature on suicidality in OCD remains limited. Thus, the present study examined the prevalence and predictors of suicidality in a sample of adults seeking treatment for OCD.MethodsA total of 687 patients seeking care through a network of intensive treatment centers consented to participate. Participants completed validated self-report questionnaires of depression and OCD symptom severity, as well as psychodiagnostic interviews.ResultsAlmost half of the participants reported current suicidal ideation. The presence of a comorbid diagnosis was associated with increased likelihood of more severe SITB. Specifically, the presence of a co-occurring anxiety, depressive, or bipolar mood disorder predicted increased severity of SITB. In addition, obsession severity was positively associated with suicidality, while compulsion severity negatively predicted the severity of SITB. Regarding OCD symptom dimensions, repugnant thoughts emerged as a significant predictor of SITB severity.ConclusionsSITB is a prevalent concern in treatment-seeking patients with OCD. Clinicians are encouraged to assess and consider the treatment implications of SITB, particularly among patients with co-occurring mood and anxiety disorders, or symptoms involving taboo thought content. Future directions and theoretical considerations are discussed.

BackgroundDepressive and obsessive-compulsive (OCD) symptoms often co-occur and a number of possible explanations for this co-occurrence have been explored, including shared biological and psychosocial risk factors. Network approaches have offered a novel hypothesis for the link between depression and OCD: functional inter-relationships across the symptoms of these conditions. The few network studies in this area have relied largely on item, rather than process-level constructs, and have not examined relationships dimensionally.MethodsNetwork analytic methods were applied to data from 463 treatment-seeking adults with OCD. Patients completed self-report measures of OCD and depression. Factor analysis was used to derive processes (i.e., nodes) to include in the network. Networks were computed, and centrality, bridge, and stability statistics examined.ResultsNetworks showed positive relations among specific OCD and depressive symptoms. Obsessions (particularly repugnant thoughts), negative affectivity, and cognitive-somatic changes (e.g., difficulty concentrating) were central to the network. Unique relations were observed between symmetry OCD symptoms and cognitive-somatic changes. No direct link between harm-related OCD symptoms and depression was observed.ConclusionsOur results bring together prior findings, suggesting that both negative affective and psychomotor changes are important to consider in examining the relationship between OCD and depression. Increased consideration of heterogeneity in the content of OCD symptoms is key to improving clinical conceptualizations, particularly when considering the co-occurrence of OCD with other disorders.

Despite empirical support for the efficacy of exposure-based therapy for anxiety-related disorders, many individuals do not respond to this intervention or else experience a return of fear after treatment. Inhibitory learning theory has informed novel approaches to exposure therapy delivery that aim to improve both short- and long-term outcomes. One exposure optimization strategy is to maximize expectancy violation (i.e., the difference between expected and actual outcomes), which is thought to strengthen inhibitory (i.e., non-threat) associations and enhance long-term fear extinction. In practice, exposure therapy is traditionally preceded by cognitive restructuring to lessen the magnitude of harm expectancies. Yet this technique may restrict the discrepancy between expected and actual outcomes, thus reducing the potency of exposure and limiting the durability of treatment gains. The present study examined the effects of manipulating the timing of cognitive techniques during exposure-based therapy by randomly assigning 45 participants with spider phobia to one of three conditions: (a) cognitive restructuring before exposure (CR-EXP; n=15), (b) exposure before cognitive restructuring (EXP-CR; n=15), and (c) stress management control (SM; n=15). Although both CR-EXP and EXP-CR were more effective than SM, there were no significant differences between CR-EXP and EXP-CR on measures of fear, avoidance, spider-related cognitions, or change in harm expectancy. Clinical implications, study limitations, and future directions are discussed.

Up to 30% of individuals with psychosis also experience significant obsessive-compulsive symptoms (OCS). This common, yet understudied, co-occurrence is associated with a more severe clinical presentation and course than psychosis alone, making identifying effective treatments for this comorbidity profile critical. This systematic review synthesized the literature published between 1976 and 2020 on psychopharmacological, psychosocial, and other treatment approaches for co-occurring OCS and psychosis. Our review identified 42 studies examining psychopharmacological (n = 32), psychosocial (n = 7), and neuromodulation (n = 3) treatments. Results suggested that there is early support for the effectiveness of tricyclic antidepressants, selective serotonin reuptake inhibitors, and cognitive behavioral therapies as augmentative agents to traditional antipsychotic medications to reduce OCS within the context of psychosis. Considerable limitations across identified studies preclude reliable conclusions about the effectiveness of treatment for co-occurring OCS and psychosis. Gaps in the identified literature point to important areas for future research.

Self-assessment and self-reflection are foundational competencies for psychologists and are integral to professional training and lifelong learning. Psychologists are expected to integrate these processes with clinical practice; identify limits to their knowledge, skills, attitudes; and demonstrate a commitment to enhancing professional competence throughout the professional lifespan. In this chapter, we present challenges associated with accurate self-assessment and self-reflection and share recommendations for addressing them in training and via intentional lifelong learning. We suggest that a communitarian perspective enhances these key competencies and serves to promote high ethical standards and improved clinical outcomes for the individuals and communities we serve.

The novel coronavirus disease (COVID-19), first detected in December of 2019 and declared a global pandemic in March of 2020, continues to pose a serious threat to public health and safety worldwide. Many individuals report anxiety in response to this threat, and at high levels, such anxiety can result in adverse mental health outcomes and maladaptive behavioral responses that have consequences for the health of communities more broadly. Predictors of excessive anxiety in response to COVID-19 are understudied. Accordingly, the present study examined psychological factors that predict more intense COVID-19-related anxiety. 438 community members completed measures assessing COVID-19-related anxiety as well as psychological variables hypothesized to predict anxious responding to the threat of COVID-19. As expected, obsessive-compulsive symptoms related to contamination, the fear of arousal-related body sensations (i.e., anxiety sensitivity), and body vigilance each predicted more severe anxiety related to the pandemic. Obsessive-compulsive symptoms related to responsibility for causing harm also emerged as a predictor. Study limitations and implications are discussed.

A growing body of scholarship suggests that art-making provides symptom relief as well as short-term mood benefits. However, more research is needed to explore how artistic activities may lead to mood improvements within the course of sessions conducted in clinical contexts. To this end, we examined short-term outcomes of participation in an art group offered within a brief partial hospital program in which intensive day treatment is delivered. In a preliminary study (Study 1) conducted on Amazon MTurk (N = 193), we validated the use of a brief 7-item self-assessment scale to capture potential outcomes of art-making identified based on a review of the literature: positive/negative mood, general self-efficacy, creative self-efficacy, activation, mindfulness, and social connectedness. In our main study (Study 2), 175 patients in a partial hospital program completed the brief instrument validated in Study 1 at the beginning and end of a 50-minute unstructured art group. All psychological outcomes improved over the course of the group. Changes in general self-efficacy and mindfulness were associated with improvements in mood over and above changes in other outcomes. Results are limited by the naturalistic, uncontrolled, design of the group, which was not led by art therapists. These findings suggest that further studies examining patients’ experiences during art-making in clinical settings may provide useful insights into how this activity enhances mood.

It is well established that the transition to new parenthood is associated with the onset or worsening of obsessive-compulsive symptoms (OCS); however, less is known regarding specific risk factors associated with the development of postpartum OCS. The present prospective study examined experiential avoidance and interpretations of intrusive thoughts as predictors of the development of postpartum OCS in first-time mothers and fathers. Participants were 64 expecting parents (33 mothers and 31 partners-all fathers) who were followed from the 2nd or 3rd trimester of pregnancy into the postpartum. All completed measures of postpartum OCS, experiential avoidance, and interpretations of intrusive thoughts. Experiential avoidance and the pre-existing tendency to misinterpret intrusive thoughts were predictors of infant-related OCS in the early postpartum, but not at six months postpartum. These findings provide support for particular psychological risk factors in the development of infant-related OCS among first-time mothers and fathers. Implications for prevention and intervention are discussed.

Exposure and response prevention (ERP) is the most effective treatment for obsessive-compulsive disorder (OCD), with robust symptom gains consistently observed. Yet, both research and clinical practice indicate ERP is not equally efficacious for all individuals with OCD, and a considerable portion fail to achieve full symptom remission or experience relapse despite substantial short-term gains. To this end, inhibitory learning theory (ILT) has emerged as an empirically driven conceptual framework for implementing ERP with the goal of optimizing the efficiency and durability of treatment gains. This chapter reviews the conceptual framework for ERP, illustrates ERP through a case example in which common pitfalls were encountered, defines ILT, and illustrates the use of ILT to address these pitfalls.

For a number of reasons, it may be critical to involve a romantic partner or spouse in exposure and response prevention (ERP) for obsessive-compulsive disorder (OCD). Indeed, relationship stress focal to OCD is associated with greater symptom severity, a more severe course, and poor global functioning. Research also indicates that involving partners or spouses to serve as coaches for their OCD-affected partners during ERP improves the efficacy of this treatment. This chapter describes the nature and treatment of OCD, focusing on interpersonal dynamics, and outlines a couple-based ERP program for individuals with OCD who are in long-term relationships. Case examples are included to illustrate the techniques used in this program.

Earworms refer to catchy tunes that run repeatedly through a person's mind. Empirical literature regarding earworms is scant; however, some researchers have conceptualized the phenomenon as an unwanted intrusion in the context of obsessive-compulsive disorder. The current study expands upon past research by characterizing the experience of earworms and examining associations of earworm-related distress and interference with theoretical constructs of interest, including obsessive beliefs and experiential avoidance. Two hundred forty participants completed an online survey regarding the experience of musical obsessions (e.g., duration, frequency, distress) and related theoretical constructs (e.g., experiential avoidance) of interest. Descriptive results regarding the frequency, duration, and associated distress and interference of earworms are presented. Furthermore, results reveal that experiential avoidance is a unique predictor of earworm-related distress and interference. Results suggest that interference and distress due to earworms may be related to attempts to suppress them. Study conclusions, limitations, and directions for future research are discussed.

Exposure and response prevention (ERP) is an effective treatment for obsessive compulsive disorder (OCD); yet, improvement rates vary and it is therefore important to examine potential predictors of outcome. The present study examined adherence with ERP homework as a predictor of (a) treatment response across OCD symptom dimensions and (b) reductions in psychological factors implicated in the maintenance of OCD. Fifty adults with OCD received manualized twice-weekly ERP as part of a treatment trial. Results indicated that treatment was effective for all OCD symptom dimensions and that greater adherence with ERP homework predicted post-treatment (but not follow-up) improvements in OCD symptoms pertaining to responsibility for harm, unacceptable obsessional thoughts, and symmetry. Adherence did not predict outcomes for contamination symptoms, however. Adherence also predicted improvement in psychological maintenance factors such as obsessive beliefs and experiential avoidance. Implications of the findings include the importance of emphasizing adherence to homework instructions, as well as the importance of considering OCD symptoms dimensionally as opposed to globally in examining predictors of treatment response.

The therapeutic alliance has been the subject of a great deal of psychotherapy research, and evidence from numerous empirical studies suggests that a strong patient-therapist relationship predicts favorable treatment outcomes. Despite the consistency of the alliance outcome relationship across treatment modalities and diagnoses, little attention has been given to this potential prognostic indicator in exposure therapy for anxiety-related disorders. Given that exposure therapy requires patients to engage in challenging and distressing activities (e.g., confrontation with feared stimuli), a strong alliance between patient and therapist is conceptually relevant to treatment. Relatively few published exposure therapy trials have included the therapeutic alliance as a process variable, and no single review summarizes findings from this body of literature. Accordingly, the purpose of this review is to provide an overview and synthesis of existing research on the alliance-outcome relationship in exposure therapy. Methodological and conceptual considerations will be discussed, and future research priorities will be identified.

This chapter focuses on the phenomenology of obsessive–compulsive disorder symptoms that develop or worsen perinatally. The content of obsessions and nature of the compulsions during this period are generally related to the protection of an unborn or newborn child and most commonly involve contamination fears during pregnancy and intrusive thoughts about harm during the postpartum period. Comorbid depressive symptoms are often present as well. Perinatal OCD symptoms are maintained by the misinterpretation of intrusive thoughts as highly significant and meaningful, overestimates of threat and responsibility for preventing harm, compulsive rituals, and avoidance of fear cues. Although research has documented an increased risk of OCD during pregnancy and the postpartum period, perinatal OCD is understudied and underrecognized relative to depression and psychosis.

Background: Research supports a relationship between insomnia and obsessive-compulsive symptoms (OCS). However, given gaps in the literature, there is a need to further examine this relationship. Specifically, the present study investigated whether there are unique associations between insomnia and specific OCS dimensions (e.g., contamination, symmetry) above and beyond any relationships with anxiety or depression. We also examined potential mediation pathways for understanding the links between insomnia, anxiety, depression, and OCS dimensions. Methods: A large sample of university students (N = 253) completed measures of insomnia, OCS, depression, anxiety, and stress symptoms. Results: The main findings indicated that insomnia severity was associated with all OCS dimensions, and most strongly with unacceptable obsessive thoughts. Regression analyses revealed that anxiety, depression, and stress fully accounted for the relationship between insomnia and OCS. Mediational analyses, however, indicated that anxiety, depression, and stress differentially explained the relationship between insomnia and specific OCS dimensions. Conclusions: Overall, our findings suggest that co-occurring symptoms (e.g., anxiety, depression) may be worthwhile to examine in future research to extend our understanding of the mechanisms through which chronic sleep deprivation exerts deleterious effects on OCS. Extending findings to clinical populations and treatment contexts may have important implications for our understanding of the links between insomnia and OCS.

BACKGROUND:Scrupulosity is a common yet understudied presentation of obsessive compulsive disorder (OCD) that is characterized by obsessions and compulsions focused on religion. Despite the clinical relevance of scrupulosity to some presentations of OCD, little is known about the association between scrupulosity and symptom severity across religious groups.AIMS:The present study examined the relationship between (a) religious affiliation and OCD symptoms, (b) religious affiliation and scrupulosity, and (c) scrupulosity and OCD symptoms across religious affiliations.METHOD:One-way ANOVAs, Pearson correlations and regression-based moderation analyses were conducted to evaluate these relationships in 180 treatment-seeking adults with OCD who completed measures of scrupulosity and OCD symptom severity.RESULTS:Scrupulosity, but not OCD symptoms in general, differed across religious affiliations. Individuals who identified as Catholic reported the highest level of scrupulosity relative to individuals who identified as Protestant, Jewish or having no religion. Scrupulosity was associated with OCD symptom severity globally and across symptom dimensions, and the magnitude of these relationships differed by religious affiliation.CONCLUSIONS:Findings are discussed in terms of the dimensionality of scrupulosity, need for further assessment instruments, implications for assessment and intervention, and the consideration of religious identity in treatment.