OBJECTIVES:Exposure and response prevention (EX/RP) is a first-line psychological treatment for obsessive-compulsive disorder (OCD), yet treatment response varies across individuals. Given the substantial heterogeneity in OCD symptom presentations, examining changes in obsessive-compulsive (O-C) symptom profiles, rather than overall symptom severity, may clarify why patients respond differently to treatment. Accordingly, this study aimed to identify O-C symptom profile classes across treatment and to characterize transitions between classes during EX/RP. METHODS:The sample included 152 patients with OCD from two clinical trials that delivered 17 twice-weekly EX/RP sessions over 8 weeks, with assessments conducted at baseline, midpoint and post-treatment. Latent profile analysis was used to identify O-C symptom profiles at each time point, followed by latent transition analysis to examine how individuals transitioned between profile classes over time. RESULTS:Distinct O-C profiles were identified at each time point, reflecting varying severity across Obsessive-Compulsive Inventory-Revised dimensions. Most patients maintained stable profiles with reduced overall symptom severity across treatment, supporting EX/RP's effectiveness. However, some profiles-particularly those characterized by elevated neutralizing symptoms-showed more variable transitions. A novel profile emerged at midpoint, with lower baseline avoidance predicting the membership. CONCLUSIONS:These findings suggest that meaningful clinical information is gained by monitoring changes in O-C symptom profiles alongside overall severity during EX/RP. In particular, elevated neutralizing symptoms may signal a more variable response, whereas hoarding elevations may warrant early identification and proactive planning for targeted strategies beyond standard EX/RP. Incorporating profile-based monitoring into clinical practice may help clinicians more precisely tailor EX/RP to maximize therapeutic benefit.

Obsessive compulsive disorder (OCD) and obsessive compulsive personality disorder (OCPD) frequently co-occur, yet the clinical implications of this comorbidity remain unclear. This study investigated the prevalence and association of OCPD in individuals with OCD in a specialized outpatient clinic. We evaluated the Pathological Obsessive-Compulsive Personality Scale (POPS) as a screening tool for OCPD in this population. A sample of 228 patients with a primary DSM-5 OCD diagnosis completed measures of OCD severity, OCPD traits/severity, quality of life, and mood. Results indicated that 25% of the sample met full DSM-5 criteria for OCPD. POPS scores were positively correlated with OCD symptom severity, depression symptoms, and anhedonia and negatively with quality of life. Controlling for demographic differences, individuals with comorbid OCPD reported greater overall OCPD severity, higher levels of OCPD traits (except Emotional Overcontrol) as well as greater OCD severity but did not differ from those without OCPD on depression symptoms, anhedonia, and quality of life. Receiver Operating Characteristic (ROC) analysis revealed that a POPS Total cut score of 178 demonstrated 80% sensitivity in detecting OCPD within this OCD sample. These results suggest that OCPD traits are common in individuals with OCD and may exacerbate OCD symptoms. The POPS demonstrates utility as a screening tool for OCPD in OCD populations and can aid clinicians in identifying patients who may benefit from further diagnostic evaluation and tailored treatment approaches addressing both OCD and OCPD symptoms.

BACKGROUND:Cross-sectional studies have reported neurocognitive performance deficits in obsessive-compulsive disorder (OCD), particularly on tasks assessing response inhibition and proactive control over stimulus-driven behaviors (task control). However, it is not clear whether these deficits represent trait-like markers of OCD or are state-dependent. METHODS:This study examined performance on two neurocognitive tasks in OCD patients (N = 26) before and after cognitive behavioral therapy (CBT) and matched healthy controls (HCs, N = 19). Tasks included the stop-signal task (assessing response inhibition) and the Object Interference (OI) task (assessing a specific form of task control). OCD patients completed these tasks and clinical ratings before and after 17 sessions of CBT delivered by expert therapists over two months. HCs completed tasks before and after 2-months. This design used CBT as a tool to reduce OCD symptoms to determine whether neurocognitive performance similarly improves. RESULTS:Results showed that OCD patients and HCs did not significantly differ in their stop-signal performance at either time point. In contrast, OCD patients exhibited impaired performance on the OI task at baseline and their OI performance improved after treatment, resolving the deficit relative to HC. LIMITATIONS:The sample size was small, particularly for the healthy control group. We also tested only two neurocognitive tasks. Future study with larger sample sizes and more tasks is warranted. CONCLUSIONS:These results suggest that task control deficits in OCD may be sensitive to symptom state. The possibility that improving task control represents a neurocognitive mechanism of successful CBT represents an important direction for future research.

Background:Cognitive-behavioral therapy (CBT) with exposure and response prevention (ERP) is a recommended treatment for obsessive-compulsive disorder (OCD), although many patients who undergo this regimen do not achieve satisfactory symptom relief, and maintaining long-term remission is challenging. Concentrated exposure therapy (cET) has emerged as a potential treatment for treatment-resistant OCD. However, the role of insight as a predictor of treatment outcomes in this context remains underexplored. Methods:We conducted a secondary analysis of a randomized controlled trial (RCT) including 163 adults diagnosed with treatment-resistant OCD. This study used linear regression models to evaluate whether pre-treatment levels of insight and changes in insight-measured by the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) insight item-were associated with outcomes after 4 days of cET and whether insight levels changed post-treatment. Results:Baseline insight did not predict OCD severity at post-treatment or 3-month follow-up but was associated with greater OCD severity at the 12-month follow-up. Insight scores improved significantly from pre- to post-treatment but worsened during the follow-up period. Notably, a change in insight during cET was a significant predictor of OCD symptom severity at all follow-up intervals. Conclusions:Baseline insight was not a strong predictor of short-term treatment outcomes following cET but was related to long-term OCD severity. Improvements in insight during cET were associated with achieving and maintaining reduced symptoms over time. These results suggest that improvements in OCD and enhanced insight are associated. Trial Registration: ClinicalTrials.gov identifier: NCT02656342.

Generative artificial intelligence (genAI) has potential to improve healthcare by reducing clinician burden and expanding services, among other uses. There is a significant gap between the need for mental health care and available clinicians in the United States-this makes it an attractive target for improved efficiency through genAI. Among the most sensitive mental health topics is suicide, and demand for crisis intervention has grown in recent years. We aimed to evaluate the quality of genAI tool responses to suicide-related queries. We entered 10 suicide-related queries into five genAI tools-ChatGPT 3.5, GPT-4, a version of GPT-4 safe for protected health information, Gemini, and Bing Copilot. The response to each query was coded on seven metrics including presence of a suicide hotline number, content related to evidence-based suicide interventions, supportive content, harmful content. Pooling across tools, most of the responses (79%) were supportive. Only 24% of responses included a crisis hotline number and only 4% included content consistent with evidence-based suicide prevention interventions. Harmful content was rare (5%); all such instances were delivered by Bing Copilot. Our results suggest that genAI developers have taken a very conservative approach to suicide-related content and constrained their models' responses to suggest support-seeking, but little else. Finding balance between providing much needed evidence-based mental health information without introducing excessive risk is within the capabilities of genAI developers. At this nascent stage of integrating genAI tools into healthcare systems, ensuring mental health parity should be the goal of genAI developers and healthcare organizations.

PURPOSE:Hoarding disorder (HD) involves difficulty discarding clutter. Existing treatments for HD (including cognitive-behavioral therapy [CBT]) yield only partial symptom reduction. Identifying factors that contribute to hoarding may inform potential treatment mechanisms. One such factor is intolerance of uncertainty (IU), the tendency to maladaptively respond to the unknown via fear, discomfort, and avoidance. While IU has been linked to hoarding symptoms, its role in treatment outcomes remains understudied. METHODS:41 adults with HD completed the Buried in Treasures (BIT+) Workshop (a 16-session manualized skills group using CBT principles, with 10 additional supervised in-home uncluttering practice). IU and HD symptom severity were assessed pre- and post-treatment. RESULTS:Pre-treatment IU did not significantly predict improvement in hoarding symptoms (β = .15, p = .31). However, IU significantly decreased following treatment (t = 2.23, p = .017). Smaller reductions in IU significantly predicted worse hoarding symptom outcomes, accounting for baseline severity (β = .41, p < .01). CONCLUSIONS:Results suggest that high initial levels of IU may not prevent patients from benefiting from hoarding treatment via the BIT+, but that reduction in IU accounts for a significant increment in hoarding treatment gains. Given the room for improvement evident in HD treatments, future research might consider augmenting existing treatment with IU-specific interventions to boost treatment efficacy.

Exposure and Response Prevention (ERP) is an effective treatment for obsessive compulsive disorder (OCD), yet the specific underlying mechanisms by which ERP improves symptoms remain unclear. Initial theories suggested that habituation to triggering events and stimuli was the key therapeutic factor in ERP, while other theories highlight the role of developing the ability to tolerate distress, rather than reduction of distress. The current study examined improvements in distress tolerance as a mechanism of OCD, anxiety, and depressive symptom reductions during an ERP based intensive program. Participants (N = 180) completed weekly measures of distress intolerance, and symptom severity of OCD, anxiety, and depression. Using Multi-Level Structural Equation Modeling, we found that participants experienced significant weekly decreases in OCD, anxiety, and depressive symptom severity across the course of their ERP based treatment. Weekly reductions in OCD symptom severity were partially accounted for by weekly improvements in participants' ability to tolerate distress, particularly for obsession symptoms. This effect was also significant for anxiety and depressive symptom severity, above-and-beyond the effects of weekly reductions in OCD symptom severity. The current study suggests improving the ability to tolerate distress represents a transdiagnostic mechanism of symptom severity reduction in OCD, anxiety, and depressive psychopathology via intensive ERP based psychotherapy programming. Limitations and future directions for improving treatments for OCD, anxiety, and depressive symptoms are discussed.

Abstract Introduction Bergen 4-Day treatment (B4DT) is a form of concentrated exposure-based cognitive behavioral therapy (CBT) in which patients receive treatment over four consecutive days. Previous studies have shown B4DT to be a promising treatment format for panic disorder (PD), although the long-term stability of treatment gains requires additional study. Aim The aim of the current study was to evaluate the longer-term effectiveness of B4DT for patients with panic disorder with or without agoraphobia. This study extends a previously published study by providing a long-term follow-up of the same cohort (n = 30), initially assessed at three months post-treatment. Method Thirty patients with panic disorder were consecutively included in a retrospect open trial. The primary outcome measure was the Panic Disorder Severity Scale. The secondary outcome measures were the Generalized Anxiety Disorder-7 and the Patient Health Questionnaire-9. Outcomes were assessed at pretreatment, posttreatment, 3-month follow-up, and longer-term follow-up (with a mean time of 18 months). Results There was a significant reduction in panic disorder symptoms from pretreatment to longer-term follow-up (d = 5.03, 95% CI [18.55, 21.12] to [1.33, 3.87]). The Panic Disorder Severity Scale (PDSS) mean decreased from 19.83 (SD = 0.64, 95% CI [18.55, 21.12]) before treatment, to 4.37 (SD = 0.64, 95% CI [2.98, 5.76]) post-treatment, followed by further decreases at the 3-month follow-up to a mean of 2.84 (SD = 0.64, 95% CI [1.45, 4.22]), and at the longer-term follow-up to 2.60 (SD = 0.64, 95% CI [1.33, 3.87]). There was no significant difference in symptom severity between the 3-month and 18-month assessments, indicating a sustained improvement (p <.001). At the 18-month follow-up, 90% of the patients were classified as being in remission. There were also significant reductions in symptoms of depression (d = 1.44) and generalized anxiety (d = 1.62) that were maintained at the longer-term follow-up assessment. Conclusion The results from the current study indicated that the treatment effects of B4DT are stable over time and that the treatment format appears to be promising for PD. Confirming these preliminary results in rigorous study designs is needed. Trial registration The study was approved by the Regional Committee for Medical and Health Research Ethics of Northern Norway (REK Nord-2021/209619).

The COVID-19 pandemic has necessitated essential modifications to the administration of psychotherapy for patients with panic disorder (PD) through the increased use of videoconferencing. However, the effect of this change on treatment efficacy remains unclear. The current study is a long-term (1.5 years) investigation of the Bergen 4-day treatment (B4DT) for PD delivered as a combination of videoconferencing and face-to-face therapy. This study reported the long-term outcomes of B4DT for PD when delivered in a hybrid format. The B4DT includes multiple components delivered over four consecutive days. As the pandemic unfolded, B4DT was adapted to include different levels of in-person versus videoconference delivery, depending on COVID-19 infection rates and public health recommendations. Outcome measures included clinician-rated illness severity on the Panic Disorder Severity Scale (PDSS) and patient-rated symptoms of PD, agoraphobia, generalized anxiety, and depression. Follow-up treatment, work status, and current medications were assessed. We used multilevel models to estimate whether clinical improvement was maintained over time. Treatment effects achieved at three months were maintained at the 1.5-year follow-up. Patients who completed the PDSS scored M = 14.78 (SD = 3.37) before treatment, M = 5.88 (5.28) at the three-month follow-up (d = 2.01), and M = 5.44 (SD = 5.12) at the long-term follow-up (d = 2.15). The reduction in generalized anxiety and depression symptoms was maintained over time. The current study suggests that B4DT can be delivered successfully in a combination of face-to-face and videoconference therapy sessions. Moreover, long-term effects are maintained, even during the challenging circumstances of the pandemic.

Background: The treatment of choice for obsessive-compulsive disorder (OCD) is exposure and response prevention (EX/RP). Previous studies have demonstrated that treatment adherence predicts treatment outcome for patients with OCD, but there is little knowledge on its role in concentrated exposure treatment for OCD.Method: In the present study, 42 patients received EX/RP treatment using the Bergen 4-day format. Adherence was measured with the Exposure and Response Prevention Adherence Scale (PEAS, rated both by patients and therapists) after the second and third day. Treatment outcome (symptoms of OCD, depression, anxiety, work- and social functioning, and well-being) was assessed at 3-month follow-up.Results: At follow-up, 71.4% were in remission. High adherence was reported (mean score of 6 on a 1–7 scale). The combination of patient- and therapist rated adherence was significantly associated with treatment outcome whilst controlling for age, sex, and pre-treatment scores. Patients with higher degree of adherence reported less symptoms, higher functioning, and more well-being at follow-up.Conclusions: The results of the present study indicated that adherence in concentrated exposure treatment is significantly associated with a wide range of treatment outcomes for OCD.

Although exposure and response prevention (ERP) is recommended for adults with obsessive-compulsive disorder (OCD), some recipients do not fully respond while others improve and subsequently relapse. Identifying factors associated with poor outcomes is therefore highly important. We investigated behavioral avoidance as one potential factor. Data came from a large randomized controlled trial that delivered a concentrated ERP protocol over the course of four consecutive days in accord with the Bergen 4-Day Treatment (B4DT). Avoidance was assessed with the auxiliary item from the Yale-Brown Obsessive-Compulsive Scale (YBOCS). Although behavioral avoidance did not predict acute outcome at immediate post-treatment, patients with substantial avoidance behaviors prior to treatment had worse long term (12-month) outcomes (increased OCD severity and greater functional impairment), after controlling for OCD severity at baseline. Avoidance significantly decreased from pre-to post-treatment but increased from post-treatment to 3-month and 12-month follow-up. Change in avoidance from post-treatment to 3-month follow-up predicted subsequent OCD worsening at 12-months, after controlling for change in global OCD severity. Results suggest that avoidant patients can benefit from ERP but may be at increased risk of poorer long-term outcomes. Future work should investigate strategies to identify and ameliorate worsening avoidance to reduce relapse.

Objective: To explore predictors and moderators of clinical worsening during a double-blind trial in which patients with obsessive-compulsive disorder (OCD) were randomized to either continue or discontinue their Serotonin Reuptake Inhibitor (SRI) medication after achieving wellness from the addition of exposure and response prevention (EX/RP) therapy.Method: The data came from a double-blind discontinuation trial that included N = 101 participants, 35 of whom were removed from the study due to clinical worsening. We first used LASSO logistic regression to identify which of the 34 potential baseline variables of interest (including demographics, diagnoses, other relevant clinical constructs, and specific genotypes), might moderate or predict this clinical worsening. Then logistic regression was used to examine which of these identified variables were significantly related to later clinical worsening. We verified the validity of our final prediction model using k-fold cross-validation.Results: There was one significant predictor of clinical worsening: In both groups, those with more past diagnoses had a greater likelihood of clinical worsening (p = .015). There were several moderators. Rates of clinical worsening were higher in the Discontinuation group compared to the Continuation group for participants who were taking a shorter half-life SRI (p = .044), were female (p = .022), had higher baseline levels of maladaptive metacognitions (p < .001), had fewer sleep problems at baseline (p = .001), and/or had more years of education (p < .001).Conclusions: Our results identified several factors that may predict the development of clinical worsening in OCD patients discontinuing SRI medication following successful EX/RP treatment.

Body dysmorphic disorder (BDD) is a severe psychiatric condition characterized by preoccupation with perceived flaws in one's appearance, which the individual views as defective or ugly. Psilocybin, a serotonin 2A receptor agonist with psychedelic properties, has emerged as a potential therapeutic agent for depression and other psychiatric disorders. This study aimed to identify subacute neural changes predicting symptomatic response to psilocybin treatment in adults with BDD. Eight adults with moderate-to-severe nondelusional BDD were administered a single oral 25 mg dose of psilocybin, accompanied by psychological support, and underwent resting state functional magnetic resonance imaging assessments 1 day before and 1 day after the dosing. Both a region of interest (ROI)-to-ROI analysis and multivariate pattern analysis (MVPA) were used to identify changes in resting state functional connectivity (rsFC) at day 1 after dosing that predicted treatment response at week 1, measured by change in Yale-Brown Obsessive Compulsive Disorder Scale Modified for BDD (BDDYBOCS) score. All participants completed the dosing and follow-up assessments over 12 weeks. BDD-YBOCS scores decreased at week 1 and week 12 after dosing (p<0.001 for both). MVPA revealed a significant increase in rsFC within the Executive Control Network (ECN) at day 1. Increased rsFC within the ECN (dlPFC - Superior Parietal Lobule [FPL]), between the ECN and Default Mode Network (dlPFC - Precuneus), and between the ECN and the Salience Network (dlPFC - insula) were predictive of improvement in BDD symptoms at week 1. These findings are the first report of subacute brain effects of psilocybin in patients with BDD. Given the small sample size and uncontrolled design of the study, larger controlled studies are necessary to validate these observations. Clinical Trials Registration: Clinicaltrials.gov ID: NCT04656301.

Objective: The Buried in Treasures (BIT) workshop is a promising treatment for hoarding disorder (HD), though many participants struggle with home uncluttering. This randomized waitlist-controlled trial investigated the efficacy of a version of BIT, augmented with in-home uncluttering practice (BIT+). Method: Adults (N = 41) with hoarding disorder were recruited from the community and randomly assigned to BIT+ or waitlist. BIT+ consisted of 16 sessions of the BIT workshop and 10 uncluttering home visits over 18 weeks. Outcome measures included the Saving Inventory-Revised (self-report) and the Clutter Image Rating Scale (self and independent evaluator rated). Between group repeated measures analyses using general linear modeling examined the effect of BIT+ vs waitlist control on hoarding symptoms after 18 weeks. Within group analyses examined pre-post effects for all BIT+ participants combined after 18 weeks. Results: After 18 weeks, BIT+ participants benefited significantly more than waitlist controls on hoarding severity with large effect size (Cohen's d = 1.5, p < .001). BIT+ was also associated with improvement reductions in hoarding symptoms, clutter, and functional impairment. Conclusions: The BIT+ intervention offers promise as a treatment option for hoarding. Adding in-home uncluttering practice may incrementally improve discarding practices. Future controlled trials are warranted.

Abstract Background Research suggests that individuals with obsessive-compulsive disorder (OCD) frequently experience insomnia. Some previous studies have suggested that insomnia may predict treatment outcomes, but the evidence is limited, especially for adolescents. This study examined the prevalence of insomnia in an adolescent OCD patient sample, explored the correlation between OCD and insomnia, and tested whether levels of insomnia at baseline predict outcomes for adolescent patients receiving the Bergen 4-Day Treatment (B4DT) for OCD. Methods Forty-three adolescent OCD patients who received B4DT were selected for this study. Treatment outcome was quantified as change in Children Yale-Brown Obsessive Compulsive Scale (CY-BOCS) scores across time from pre- to posttreatment and 3-month follow-up. Insomnia symptoms were measured by the Bergen Insomnia Scale (BIS). Linear mixed models were used to examine the relationship between the BIS and changes in CY-BOCS scores. We controlled for symptoms of general anxiety disorder measured by the GAD-7 and depression symptoms measured by the PHQ-9. Results In this sample, 68.4% of the patients scored above the cutoff for insomnia on the BIS. There was a moderate correlation between baseline CY-BOCS and BIS that did not reach statistical significance (r = .32, p = .051). High BIS scores before treatment were significantly associated with poorer treatment outcomes, as measured by changes in CY-BOCS over time (p = .002). The association between baseline insomnia and change in OCD symptoms remained significant (p = .033) while controlling for GAD-7 and PHQ-9. Conclusion Insomnia is common among adolescents with OCD, and these data suggest that these patients may be at increased risk for poor treatment outcomes. Future research to explore mechanisms and adjunctive treatments is warranted. Trial registration The study was approved by the Regional Committee for Medical and Health Research Ethics of Northern Norway (REK Nord: 2023/606482).

Background B4DT is a concentrated treatment format with prolonged sessions of exposure and ritual prevention (ERP) delivered over four consecutive days. Two previous open trials demonstrated promising results of the Bergen 4-day treatment (B4DT) for adolescents with obsessive-compulsive disorder (OCD). The aim of the current study was to replicate the initial results with a new sample of adolescents and different therapists at different sites across Norway. Methods Forty-three youths participated in treatment program. At pretreatment, posttreatment, and the three-month follow-up, OCD symptoms were assessed using the CY-BOCS interview, while the GAD-7 and PHQ-9 were administered to rate general anxiety symptoms and depressive symptoms. Acceptability and patient satisfaction with the treatment were rated with the CSQ-8. Results All symptoms were significantly reduced at posttreatment and follow-up. At posttreatment, 36 patients (85.71%) were defined as responders, while 29 patients (69.05%) achieved remission. At the three-month follow-up, 36 patients (92.3%) were defined as responders, while 33 patients (84.62%) were in remission. CSQ-8 scores indicated that the patients were highly satisfied with the treatment. Conclusions The B4DT was successfully replicated in a new sample at different sites across Norway, which indicates that this treatment is generalizable, effective and acceptable to adolescents with OCD.

Exposure and response prevention (EX/RP) is a recommended psychotherapy for obsessive-compulsive disorder (OCD). Yet, not all patients benefit equally from EX/RP. Prior studies have examined EX/RP predictors by predicting endpoint symptoms and/or pre-post symptom change, rather than accounting for trajectories of symptom change across treatment. We pooled data from four NIMH-funded clinical trials, yielding a large sample (N = 334) of adults who received a standard course of manualized EX/RP. Independent evaluators rated OCD severity using the Yale-Brown Obsessive-Compulsive Scale (YBOCS). Data were analyzed using growth mixture modeling (GMM) to detect subgroups of participants with similar trajectories of symptom change followed by multinomial logistic regression to identify baseline variables capable of predicting class membership. GMM revealed three distinct trajectory classes: 22.5% of the sample showed dramatic improvement (dramatic progress class), 52.1% showed moderate improvement (moderate progress class), and 25.4% showed little change (little to no progress class). Membership in the little to no progress class was predicted by baseline avoidance and transdiagnostic internalizing factor levels. These findings suggest that OCD symptom improvement with outpatient EX/RP occurs via distinct trajectories. These findings have implication regarding identifying treat-ment non-responders and personalizing treatment depending one's baseline characteristics in order to optimize treatment effectiveness.

Body dysmorphic disorder (BDD) is an often severe condition in which individuals are preoccupied by perceived flaws in their appearance that they believe to be defective or ugly. Psilocybin is a serotonin 2A receptor (5-HT2A) agonist with psychedelic properties that has recently been investigated as a treatment for depression. This study aimed to understand the neural correlates of the acute effects of psilocybin treatment in adults with BDD.