Publications by authors named "Bradley C Riemann"

52 Publications

Intolerance of uncertainty and obsessive-compulsive disorder dimensions.

J Anxiety Disord 2021 May 8;81:102417. Epub 2021 May 8.

Department of Psychology and Neuroscience, University of North Carolina-Chapel Hill, 235 E. Cameron Ave, Chapel Hill, NC, 27514, USA.

Intolerance of uncertainty (IU), which can include prospective (i.e., desire for predictability) and inhibitory (i.e., uncertainty paralysis) IU, is widely understood to be a central underlying component of obsessive-compulsive disorder (OCD). IU has several treatment implications, yet research on the differences in IU underlying OCD dimensions is limited and does not account for covarying effects of overlapping symptoms, shared variance in IU, demographic variables, and comorbid psychiatric conditions like generalized anxiety disorder (GAD) and posttraumatic stress disorder (PTSD). A sample of 974 patients with diagnosed OCD enrolled in residential, partial hospitalization, and intensive outpatient treatment programs for OCD and anxiety completed self-report measures of OCD symptoms and IU at admission. Structural equation modeling included prospective. inhibitory IU, and common IU and covariates (i.e., race, ethnicity, level of care, and comorbid GAD and PTSD) as predictors of four common OCD dimensions found that contamination and unacceptable thoughts symptoms evidenced a unique relationship with IU. Specifically, whereas a common IU factor predicted all four OCD symptom dimensions, inhibitory IU uniquely predicted contamination and unacceptable thoughts symptoms over and above covarying effects. Individuals with contamination and unacceptable thoughts symptoms may be more likely to feel "paralyzed" by uncertainty due to overreliance on overt immediate rituals, outright avoidance, rumination, or difficulties with emotion regulation, and may benefit from additional psychoeducation, problem-solving, and accountability. Broadly, individuals with OCD may benefit from explicit discussions about IU-related expectancies and disconfirmation of fears.
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http://dx.doi.org/10.1016/j.janxdis.2021.102417DOI Listing
May 2021

The effects of depression on the treatment of OCD in a residential sample.

Bull Menninger Clin 2020 Oct;84(Supplement A):12-33

Rogers Behavioral Health, Oconomowoc, Wisconsin.

Studies investigating the impact of depressive symptoms on obsessive-compulsive disorder (OCD) treatment have yielded mixed findings. The purpose of the study is to extend previous research, which primarily used outpatient samples, to determine whether depression affects OCD treatment outcome among patients receiving intensive residential treatment. OCD patients receiving residential treatment based primarily on exposure and response prevention (ERP) provided data regarding symptoms of depression and OCD at admission and discharge. Patients reported large and significant reductions in OCD symptoms over the course of treatment. Change in OCD symptoms was not significantly affected by depressive symptoms, including patients with severe depressive symptoms. Change in depressive symptoms over the course of treatment was, however, robustly related to change in OCD symptoms, especially among patients who began treatment with severe symptoms of depression. These findings suggest that cognitive-behavior therapy delivered in a residential treatment setting drastically reduces OCD symptoms regardless of depressive symptoms.
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http://dx.doi.org/10.1521/bumc.2020.84.suppA.12DOI Listing
October 2020

Little Doubt That CBT Works for Pediatric OCD.

J Am Acad Child Adolesc Psychiatry 2020 07 25;59(7):785-787. Epub 2020 Jun 25.

Baylor College of Medicine, Houston, Texas.

We write with great concern in response to the recent systematic review and meta-analysis of cognitive-behavioral therapy (CBT) in pediatric obsessive-compulsive disorder (OCD) by Uhre et al. Although the authors' results consistently support the clinical efficacy of CBT for pediatric OCD, we expect that, much like ourselves, readers will be confused by the discordant and inappropriate conclusions that they put forward. These conclusions stem from the authors' application and interpretation of their particular qualitative methods, which could lead important stakeholders (eg, parents, patients, clinicians, and payers) to wrongly discount clear evidence for what is known to be the best evidence-based therapy for pediatric OCD.
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http://dx.doi.org/10.1016/j.jaac.2020.01.026DOI Listing
July 2020

Cost-Effectiveness of Treatment Alternatives for Treatment-Refractory Pediatric Obsessive-Compulsive Disorder.

J Anxiety Disord 2020 01 31;69:102151. Epub 2019 Oct 31.

Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States.

Purpose: Current guidelines for first-line treatment of childhood OCD are cognitive-behavioral therapy (CBT) utilizing exposure and response prevention (ERP), and/or antidepressant (ADM) pharmacotherapy, specifically serotonin reuptake inhibitors (SRI). Given that first-line are relatively similar in terms of clinical effectiveness, the role of costs to provide such services may help influence treatment decisions. In the case of treatment refractory pediatric OCD, this cost-effectiveness analysis (CEA) aims to further evaluate two additional, higher intensity combination therapies, namely OCD-specific Intensive Outpatient (IOP) and Partial Hospitalization Programs (PHP), to determine the additional benefits, in terms of effectiveness, that may result, and the corresponding increase in costs for these higher-intensity courses of therapy.

Results: IOP was the most cost-effective strategy in terms of change in CY-BOCS, pre/post treatment, equal to 16.42 units, followed by PHP and CBT monotherapy augmented with ADM CBT-monotherapy augmented with additional CBT and ADM-only augmented with CBT followed closely with 15.56 and 14.75 unit improvements in CY-BOCS. IOP accomplished its superior cost-effectiveness with an Incremental Cost-Effectiveness Ratio (ICER), of $48,834, lower than either of the established willingness to Pay thresholds.

Conclusions: Lack of access to high fidelity, high dose CBT paired with pharmacotherapy is an issue for OCD patients and families. Among youth who were treatment non-responsive, these results indicate the superiority of a high dosage CBT strategy, indicating the need to increase access to these treatments.
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http://dx.doi.org/10.1016/j.janxdis.2019.102151DOI Listing
January 2020

Obsessive-compulsive symptoms in eating disorders: A network investigation.

Int J Eat Disord 2020 03 20;53(3):362-371. Epub 2019 Nov 20.

Department of Psychology, Harvard University, Cambridge, Massachusetts.

Objective: Eating disorders (EDs) are complex, heterogeneous, and severe psychiatric syndromes. They are highly comorbid with obsessive-compulsive disorder (OCD) which exacerbates the course of illness and impedes treatment. However, the direct functional relations between EDs and OCD symptoms remain largely unexplored. Hence, using network analysis, we investigated the relationship between ED and OCD at the level of symptoms in a heterogeneous clinical sample.

Method: We used cross sectional data of 303 treatment-seeking patients with clinically relevant ED and OCD pathology. We constructed a regularized partial correlation network that featured both ED and OCD symptoms as nodes. To determine each symptom's influence, we calculated expected influence (EI) as an index of symptom centrality (i.e., "importance"). Bridge symptoms (i.e., symptoms from one syndromic cluster that have strong connections to symptoms of another syndromic cluster) were identified by computing bridge expected influence metrics.

Results: Fear of weight gain and dietary restraint were especially important among the ED symptoms. Interference due to obsessions was the key feature of OCD. ED and OCD clustered distinctly with few potential bridges between clusters.

Discussion: This study underscores the importance of cognitive symptoms for both ED and OCD although direct functional links between the two clusters are missing. Potentially, a network incorporating nodes capturing features of personality may account for diagnostic comorbidity better than specific symptoms of EDs or features of OCD do.
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http://dx.doi.org/10.1002/eat.23196DOI Listing
March 2020

Behavioral Activation as a Mechanism of Change in Residential Treatment for Mood Problems: A Growth Curve Model Analysis.

Behav Ther 2019 11 18;50(6):1087-1097. Epub 2019 May 18.

Rogers Behavioral Health.

Research on the efficacy, effectiveness, and dissemination potential of behavioral activation (BA)-focused interventions for depression and comorbid disorders has expanded rapidly. However, research that examines how BA interventions work has seen less growth. A primary purported mechanism of BA is activation, which reflects a person's meaningful (re)engagement in life. BA theory posits that depression will decrease as activation increases, and that changes in the mechanism variable will lead to changes in outcome. The current study aims to investigate activation as a potential mechanism of change in the context of a BA-focused residential treatment intervention for mood problems using repeated measures of self-reported activation and depression from a large comorbid sample (N = 578). Growth curve modeling was used to examine between-person differences in within-person change over time. Findings suggest that self-reported activation increases and depression decreases over time. Moreover, results show both linear and quadratic growth and that the rate of change in activation predicts the rate of change of depression. BA-focused residential treatment may facilitate activation, which exerts an effect on depression among residents with diagnostically complex presentations.
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http://dx.doi.org/10.1016/j.beth.2019.05.004DOI Listing
November 2019

Predictors of acute outcomes for intensive residential treatment of obsessive-compulsive disorder.

Clin Psychol Psychother 2019 Nov 8;26(6):661-672. Epub 2019 Aug 8.

Department of Psychology, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA.

For those who suffer with chronic and disruptive obsessive-compulsive disorder (OCD), who have not been sufficiently helped by outpatient treatments or medications, intensive residential treatment (IRT) is often the next best treatment option. To date, research of the predictors of treatment outcome in IRT for OCD are mixed and sometimes contradictory. Additionally, although comorbidity is common for patients in this setting, the inclusion of comorbidity as a potential predictor of outcome has been mostly lacking in research to date. The current study aimed to address these issues by utilizing optimal indices of treatment outcomes, while incorporating comorbidity into our analyses, in order to identify the predictors of treatment outcomes in the IRT for OCD setting. To this end, we analysed outcome data from 379 patients receiving IRT for OCD at the Rogers Memorial OCD Center between August 2012, and December 2017. Results indicated that the most important predictor of treatment outcome was obsession severity at admission. Specifically, higher obsession severity at admission predicted poorer treatment outcomes at discharge. Clinical implications and suggestions for future research were discussed in the manuscript.
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http://dx.doi.org/10.1002/cpp.2389DOI Listing
November 2019

Predictors of treatment outcome for youth receiving intensive residential treatment for obsessive-compulsive disorder (OCD).

Cogn Behav Ther 2020 07 17;49(4):294-306. Epub 2019 Jun 17.

Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine , Houston, TX, USA.

Little is known about the predictors of outcome from intensive residential treatment of OCD. This study aimed to examine age, gender, and baseline OCD severity, as well as measures of comorbid anxiety and depressive, internalizing/externalizing, and inattention symptoms, as predictors of treatment outcome in adolescents receiving intensive residential treatment for OCD. The sample comprised 314 adolescents aged 13-17 years with treatment-resistant OCD and a Children's Yale-Brown Obsessive-Compulsive Scale Self-Report (CY-BOCS-SR) total score ≥16. Bivariate and multiple regression models were used to evaluate the predictors of continuous OCD severity outcome and treatment response. Results of the bivariate regression analyses of predictors demonstrated that length of treatment, pre-treatment OCD severity, and symptoms of anxiety and depression significantly predicted post-treatment OCD severity, while only symptoms of depression and anxiety predicted treatment response. When including all predictors in the same model, only baseline OCD severity remained a significant predictor of post-treatment OCD severity, and none of the assessed variables significantly predicted treatment response. Results indicate that low pre-treatment OCD severity predicts lower OCD severity following treatment, although it did not predict treatment response.
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http://dx.doi.org/10.1080/16506073.2019.1614977DOI Listing
July 2020

Predictors of concurrent depressive symptoms in patients with obsessive-compulsive disorder.

Psychiatry Res 2019 09 4;279:267-271. Epub 2019 Apr 4.

Rogers Memorial Hospital, Oconomowoc, WI, USA.

Many patients with obsessive-compulsive disorder (OCD) exhibit concurrent depressive symptoms, which are associated with negative psychological outcomes. Yet little research has focused on identifying factors that predict depressive symptoms in OCD. The current study examined three transdiagnostic constructs-anxiety sensitivity (AS), intolerance of uncertainty (IU), and worry-as predictors of depressive symptom severity in a sample of treatment-seeking adults with a primary diagnosis of OCD (N = 93). Strong, positive associations between depressive symptoms and measures of AS, IU, and worry were detected, and AS and worry (but not IU) remained significant unique predictors of depression after controlling for the severity of OCD symptoms. The conceptual and clinical implications of these findings, as well as study limitations and future directions, are discussed.
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http://dx.doi.org/10.1016/j.psychres.2019.03.052DOI Listing
September 2019

Affective forecasting accuracy in obsessive compulsive disorder.

Behav Cogn Psychother 2019 Sep 27;47(5):573-584. Epub 2019 Mar 27.

Department of Psychology, Harvard University, William James Hall, 33 Kirkland Street, Cambridge, MA 02138, USA.

Background: Research indicates that people suffering from obsessive compulsive disorder (OCD) possess several cognitive biases, including a tendency to over-estimate threat and avoid risk. Studies have suggested that people with OCD not only over-estimate the severity of negative events, but also under-estimate their ability to cope with such occurrences. What is less clear is if they also miscalculate the extent to which they will be emotionally impacted by a given experience.

Aims: The aim of the current study was twofold. First, we examined if people with OCD are especially poor at predicting their emotional responses to future events (i.e. affective forecasting). Second, we analysed the relationship between affective forecasting accuracy and risk assessment across a broad domain of behaviours.

Method: Forty-one OCD, 42 non-anxious, and 40 socially anxious subjects completed an affective forecasting task and a self-report measure of risk-taking.

Results: Findings revealed that affective forecasting accuracy did not differ among the groups. In addition, there was little evidence that affective forecasting errors are related to how people assess risk in a variety of situations.

Conclusions: The results of our study suggest that affective forecasting is unlikely to contribute to the phenomenology of OCD or social anxiety disorder. However, that people over-estimate the hedonic impact of negative events might have interesting implications for the treatment of OCD and other disorders treated with exposure therapy.
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http://dx.doi.org/10.1017/S1352465819000134DOI Listing
September 2019

Standard of proof and intolerance of uncertainty in obsessive-compulsive disorder and social anxiety disorder.

J Behav Ther Exp Psychiatry 2019 09 6;64:36-44. Epub 2019 Feb 6.

Department of Psychology, Harvard University, Cambridge, MA, USA.

Background And Objectives: Researchers have identified intolerance of uncertainty (IU) as a dysfunctional thought that contributes to OCD. Case examples of OCD suggest that uncertainty and anxiety persist despite low likelihoods of feared outcomes. In this study we examined how people with OCD react to minimal amounts of uncertainty relative to non-anxious individuals and a clinical comparison group of people with social anxiety disorder (SAD).

Methods: We created a questionnaire to measure the distress people feel when there is only minimal uncertainty regarding a given outcome and if they prefer situations with the certainty of negative outcomes in the present versus living with uncertainty. Part two of our study tested whether IU is related to performance on neutral and idiographic versions of the Beads Task.

Results: OCD and SAD subjects reacted to hypothetical scenarios involving minimal risk with greater negative affect than did non-anxious subjects; however, after repeating analyses to account for comorbid disorders, OCD subjects' scores did not differ from those of non-anxious subjects. Only SAD subjects showed a preference for negative information in the present versus the uncertainty of a future outcome. Part two of our study revealed that self-reported IU was only marginally associated with performance on the neutral Beads Task.

Limitations: High rates of comorbidity made it difficult to identify the specific relationship of IU with other anxiety disorders.

Conclusions: IU for general, non-OCD specific scenarios may not figure prominently in all individuals with OCD, but rather may play a larger, more consistent role in anxiety disorders such as SAD. Additionally, the number of beads or words viewed on Beads Task may be an inadequate behavioral measure of IU.
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http://dx.doi.org/10.1016/j.jbtep.2019.02.002DOI Listing
September 2019

Does Exposure and Response Prevention Behaviorally Activate Patients With Obsessive-Compulsive Disorder? A Preliminary Test.

Behav Ther 2019 01 1;50(1):214-224. Epub 2018 Jun 1.

Rogers Memorial Hospital.

Exposure and response prevention (ERP) and behavioral activation (BA) are effective treatments for obsessive-compulsive disorder (OCD) and depression, respectively. Patients with OCD often exhibit depression; furthermore, ERP for OCD is associated with reduced depressive symptoms. To our knowledge, no study has examined whether ERP itself functions to behaviorally activate patients with concurrent OCD and depressive symptoms. This prospective study was designed to test the hypotheses that (a) OCD exposure hierarchy completion, increased BA, and depressive symptom reduction would all be related, and (b) pre- to posttreatment changes in BA would mediate the direct effect of OCD hierarchy completion on posttreatment depressive symptoms, even after controlling for pretreatment depressive symptoms, pretreatment BA, pre- to posttreatment reductions in OCD symptoms, treatment duration, and antidepressant medication use. Patients (N = 90) with a primary diagnosis of OCD who received residential ERP for OCD completed a self-report battery at pre- and posttreatment. Exposure hierarchy completion, increases in BA, and decreases in depression were all significantly correlated (rs ranged .33 to .44). The effect of hierarchy completion on posttreatment depressive symptoms was fully mediated by pre- to posttreatment changes in BA. Findings highlight the potential for ERP to exert antidepressant effects by behaviorally activating patients. Limitations, clinical implications, and future directions are discussed.
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http://dx.doi.org/10.1016/j.beth.2018.05.007DOI Listing
January 2019

Scrupulosity, Religious Affiliation and Symptom Presentation in Obsessive Compulsive Disorder.

Behav Cogn Psychother 2019 Jul 15;47(4):478-492. Epub 2019 Jan 15.

University of North Carolina at Chapel Hill,Davie Hall,Campus Box 3270,Chapel Hill,NC 27599,USA.

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.
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http://dx.doi.org/10.1017/S1352465818000711DOI Listing
July 2019

Identifying a male clinical cutoff on the Eating Disorder Examination-Questionnaire (EDE-Q).

Int J Eat Disord 2018 12 27;51(12):1357-1360. Epub 2018 Nov 27.

Department of Psychology, University of South Florida, Tampa, Florida.

Objective: Evidence suggests that eating disorders (EDs) may be under-detected in males. Commonly used measures of EDs such as the Eating Disorder Examination-Questionnaire (EDE-Q) were initially developed within female samples, raising concern regarding the extent to which these instruments may be appropriate for detecting EDs in males. The current study used receiver operating characteristic curve analysis to (a) examine the accuracy of the EDE-Q global score in correctly classifying males with and without clinically significant ED pathology, and (b) establish the optimal EDE-Q global clinical cutoff for males.

Method: Participants were a clinical sample of 245 male ED patients and a control sample of 205 male undergraduates.

Results: Eating Disorder Examination-Questionnaire global scores demonstrated moderate-high accuracy in predicting ED status (area under the curve = 0.85, 95% CI: 0.82-0.89). The optimal cutoff of 1.68 yielded a sensitivity of 0.77 and specificity of 0.77.

Discussion: Overall, results provide preliminary support for the discriminant validity of EDE-Q scores among males. However, concerns remain regarding the measure's ability to comprehensively assess domains of disordered eating most relevant to males. Therefore, careful attention to the possibility for measurement bias and continued evaluation of the scale in males is encouraged.
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http://dx.doi.org/10.1002/eat.22972DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6310481PMC
December 2018

Predictive Relationship Between Parental Beliefs and Accommodation of Pediatric Anxiety.

Behav Ther 2018 07 21;49(4):580-593. Epub 2017 Nov 21.

Illawarra Anxiety Clinic.

Behavior performed by parents to assist a youth in avoiding or alleviating anxiety, known as accommodation, is ubiquitous among pediatric anxiety disorders and strongly related to poor treatment outcome. According to cognitive-behavioral theory, the beliefs parents hold regarding accommodation should predict parental accommodating behavior. Unfortunately, little is known about the beliefs parents hold regarding accommodation, as there exists no validated measure of this construct. First, the psychometric properties were examined for the Parental Accommodation Scale (PAS), a novel measure of parental accommodating behavior frequency (PAS-Behavior scale) and parental beliefs about accommodation (PAS-Belief scale). Second, the relationship between parental beliefs about accommodation and accommodation frequency was examined. Results provide preliminary evidence of the internal consistency and convergent validity of the PAS. Stronger positive beliefs about accommodation significantly predicted accommodation frequency, even after controlling for youth anxiety severity. Specifically, beliefs that accommodation prevents youth from losing behavioral and emotional control significantly predicted accommodation frequency. Therefore, efforts to decrease accommodation in clinical settings should involve correcting maladaptive parental beliefs about accommodation, with a particular emphasis on beliefs regarding the necessity of accommodation in preventing a youth from losing behavioral and emotional control.
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http://dx.doi.org/10.1016/j.beth.2017.11.004DOI Listing
July 2018

A comparative network analysis of eating disorder psychopathology and co-occurring depression and anxiety symptoms before and after treatment.

Psychol Med 2019 01 15;49(2):314-324. Epub 2018 Apr 15.

Center for Psychotherapy Research,University Hospital Heidelberg,Heidelberg,Germany.

Background: Network analysis is an emerging approach in the study of psychopathology, yet few applications have been seen in eating disorders (EDs). Furthermore, little research exists regarding changes in network strength after interventions. Therefore the present study examined the network structures of ED and co-occurring depression and anxiety symptoms before and after treatment for EDs.

Method: Participants from residential or partial hospital ED treatment programs (N = 446) completed assessments upon admission and discharge. Networks were estimated using regularized Graphical Gaussian Models using 38 items from the Eating Disorders Examination-Questionnaire, Quick Inventory of Depressive Symptomatology, and State-Trait Anxiety Inventory.

Results: ED symptoms with high centrality indices included a desire to lose weight, guilt about eating, shape overvaluation, and wanting an empty stomach, while restlessness, self-esteem, lack of energy, and feeling overwhelmed bridged ED to depression and anxiety symptoms. Comparisons between admission and discharge networks indicated the global network strength did not change significantly, though symptom severity decreased. Participants with denser networks at admission evidenced less change in ED symptomatology during treatment.

Conclusions: Findings suggest that symptoms related to shape and weight concerns and guilt are central ED symptoms, while physical symptoms, self-esteem, and feeling overwhelmed are links that may underlie comorbidities in EDs. Results provided some support for the validity of network approaches, in that admission networks conveyed prognostic information. However, the lack of correspondence between symptom reduction and change in network strength indicates that future research is needed to examine network dynamics in the context of intervention and relapse prevention.
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http://dx.doi.org/10.1017/S0033291718000867DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6310232PMC
January 2019

Treatment-Refractory Obsessive-Compulsive Disorder in Adults: A Cost-Effectiveness Analysis of Treatment Strategies.

J Clin Psychiatry 2018 Mar/Apr;79(2)

Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA.

Objective: This study sought to assess the cost-effectiveness of 7 treatment strategies for treatment-refractory obsessive-compulsive disorder (OCD) in adults.

Methods: A model was developed to evaluate treatment alternatives for adults (18-64 years old) that consisted of 2 parts: a decision analytic model and a Markov model. The decision analytic model stratified 7 outpatient treatment strategies, and the Markov model accumulated benefits and costs across the life expectancy of a simulated cohort of individuals. The model was parameterized with probabilistic and deterministic parameters from the literature and an outcomes database to perform a Monte Carlo simulation of a hypothetical cohort of 100,000 adults with OCD to estimate net health benefits (NHBs), costs, and incremental cost-effectiveness ratio (ICER) for each treatment strategy. OCD was considered treatment refractory in adults with an OCD diagnosis who failed first-line therapies. Encounters took place from 2012 to 2015, and the analyses were performed from November 2016 to February 2017.

Results: Partial hospitalization with step-down to intensive outpatient treatment was the most cost-effective of the 7 strategies, with an estimated ICER of $7,983 and mean (SD) NHB of 10.96 (0.53) quality-adjusted life-years (QALYs) remaining. This result was 2.2 QALYs greater than that of the trial-based antidepressant and cognitive-behavioral therapy (ADM + CBT) strategy. Three additional ADM + CBT strategies were estimated not to be statistically significantly different from each other. These 4 ADM + CBT strategies outperformed both pharmacotherapy-only strategies.

Conclusions: Treatment strategies that include higher-intensity CBT, with effectiveness outcomes that approached efficacy estimates, were superior to real-world CBT strategies. However, given the limited availability of high-quality CBT, especially through use of commercial insurance networks, specialized treatment programs offer greater effectiveness than real-world therapies in achieving wellness for this severe patient population.
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http://dx.doi.org/10.4088/JCP.17m11552DOI Listing
June 2019

Treatment-Refractory Obsessive-Compulsive Disorder in Adults: A Cost-Effectiveness Analysis of Treatment Strategies.

J Clin Psychiatry 2018 Mar/Apr;79(2)

Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA.

Objective: This study sought to assess the cost-effectiveness of 7 treatment strategies for treatment-refractory obsessive-compulsive disorder (OCD) in adults.

Methods: A model was developed to evaluate treatment alternatives for adults (18-64 years old) that consisted of 2 parts: a decision analytic model and a Markov model. The decision analytic model stratified 7 outpatient treatment strategies, and the Markov model accumulated benefits and costs across the life expectancy of a simulated cohort of individuals. The model was parameterized with probabilistic and deterministic parameters from the literature and an outcomes database to perform a Monte Carlo simulation of a hypothetical cohort of 100,000 adults with OCD to estimate net health benefits (NHBs), costs, and incremental cost-effectiveness ratio (ICER) for each treatment strategy. OCD was considered treatment refractory in adults with an OCD diagnosis who failed first-line therapies. Encounters took place from 2012 to 2015, and the analyses were performed from November 2016 to February 2017.

Results: Partial hospitalization with step-down to intensive outpatient treatment was the most cost-effective of the 7 strategies, with an estimated ICER of $7,983 and mean (SD) NHB of 10.96 (0.53) quality-adjusted life-years (QALYs) remaining. This result was 2.2 QALYs greater than that of the trial-based antidepressant and cognitive-behavioral therapy (ADM + CBT) strategy. Three additional ADM + CBT strategies were estimated not to be statistically significantly different from each other. These 4 ADM + CBT strategies outperformed both pharmacotherapy-only strategies.

Conclusions: Treatment strategies that include higher-intensity CBT, with effectiveness outcomes that approached efficacy estimates, were superior to real-world CBT strategies. However, given the limited availability of high-quality CBT, especially through use of commercial insurance networks, specialized treatment programs offer greater effectiveness than real-world therapies in achieving wellness for this severe patient population.
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http://dx.doi.org/10.4088/JCP.17m11552DOI Listing
June 2019

Intensive family exposure-based cognitive-behavioral treatment for adolescents with anorexia nervosa.

Psicothema 2017 Nov;29(4):433-439

Catholic University of Murcia.

Background: Anorexia nervosa exhibits high comorbidity rates and shared features with anxiety disorders and obsessive-compulsive disorder. Anxiety-based etiological models have proposed that fear of eating-related stimuli is the central mechanism around which avoidance of food and food-related rituals are performed. Building on this approach, exposure-based interventions have demonstrated promising results. Limited evidence in adolescents encourages the evaluation of exposure approaches in this population.

Method: The current study presents a preliminary evaluation, in eight adolescents with anorexia nervosa, of an exposure-based CBT featuring an intensive format and parental involvement.

Results: significant improvements in physical and psychological outcomes were observed.

Conclusions: this case series provides preliminary support for the efficacy of intensive family exposure-based CBT for treating adolescents with severe anorexia nervosa.
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http://dx.doi.org/10.7334/psicothema2016.372DOI Listing
November 2017

Multimodal Residential Treatment for Adolescent Anxiety: Outcome and Associations with Pre-treatment Variables.

Child Psychiatry Hum Dev 2018 Jun;49(3):434-442

Department of Pediatrics, Rothman Center for Pediatric Neuropsychiatry, University of South Florida, St. Petersburg, FL, USA.

This study aimed to determine the effect of a multimodal residential treatment program for severe adolescent anxiety, and examine whether treatment outcome was associated with pre-treatment anxiety, comorbid disorders, or participant age or gender. Participants were 70 adolescents (61.4% female, mean age = 15.4 years) with a primary anxiety disorder who received residential treatment involving cognitive behavioral therapy and medication management. Treatment outcome was assessed both as the change in adolescent-reported anxiety symptoms, and using treatment response criteria. Results indicated a strong effect of the intervention on symptoms of anxiety, depression, and anxiety-related life interference. Most pre-treatment variables were not associated with treatment outcome. However, higher adolescent-reported pre-treatment anxiety was associated with a greater reduction in anxiety at post-treatment, and the presence of a comorbid anxiety disorder was associated with poorer odds of treatment response. Findings indicate that residential treatment is a robust intervention for adolescent anxiety.
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http://dx.doi.org/10.1007/s10578-017-0762-8DOI Listing
June 2018

Family accommodation of anxiety symptoms in youth undergoing intensive multimodal treatment for anxiety disorders and obsessive-compulsive disorder: Nature, clinical correlates, and treatment response.

Compr Psychiatry 2018 01 3;80:1-13. Epub 2017 Aug 3.

Department of Pediatrics, Rothman Center for Neuropsychiatry, University of South Florida, 880 6th Street South, Suite 460, Box 7523, St. Petersburg, FL 33701, USA; Rogers Behavioral Health - Tampa, 2002, North Lois Ave, Tampa Bay, Tampa, FL, 33607, USA; Department of Psychology, University of South Florida, 4202 East Fowler Ave, PCD4118G, Tampa, FL 33620, USA; Department of Psychiatry and Behavioral Neurosciences, University of South Florida, 3515 E. Fletcher Ave., Tampa, FL 33613, USA; Department of Health Management and Policy, University of South Florida, 13201 Bruce B. Downs Blvd., MDC56, Tampa, FL 33612-3805, USA; Johns Hopkins All Children's Hospital, 501 6th Avenue South, St. Petersburg, FL 33701, USA. Electronic address:

Background: Family accommodation is associated with a range of clinical features including symptom severity, functional impairment, and treatment response. However, most previous studies in children and adolescents investigated family accommodation in samples of youth with obsessive-compulsive disorder (OCD) or anxiety disorders receiving non-intensive outpatient services.

Aims: In this study, we aimed to investigate family accommodation of anxiety symptoms in a sample of youth with clinical anxiety levels undergoing an intensive multimodal intervention for anxiety disorders or OCD.

Procedures: We first assessed the internal consistency of the Family Accommodation Scale - Anxiety (FASA). We next examined family accommodation presentation and correlates.

Results: The FASA showed high internal consistency for all subscales and total score, and good item and subscale correlations with the total score. All parents reported at least mild accommodation, and the mean levels of family accommodation were particularly high. Child age, anxiety severity, and comorbid depressive symptoms predicted baseline accommodation. However, the association between anxiety severity and family accommodation no longer remained significant after adding the other factors to the model. In addition, family accommodation partially mediated the relationship between anxiety severity and functional impairment. Finally, post-treatment changes in family accommodation predicted changes in symptom severity and functional impairment.

Conclusions: These findings suggest the FASA is an appropriate tool to assess family accommodation in intensive treatment samples. Further, they underline the importance of addressing family accommodation in this population given the particularly high levels of accommodating behaviors and the evidence for adverse outcomes associated with this feature.
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http://dx.doi.org/10.1016/j.comppsych.2017.07.012DOI Listing
January 2018

Predictors of illness anxiety symptoms in patients with obsessive compulsive disorder.

Psychiatry Res 2017 10 5;256:417-422. Epub 2017 Jul 5.

Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA. Electronic address:

Illness anxiety and OCD symptoms appear to overlap in their presentation as well as in other conceptually important ways (e.g., dysfunctional cognitions). Little research, however, has directly examined these putative relationships. The present study examined the extent to which illness anxiety symptoms were associated with OCD symptom dimensions and relevant cognitive factors in a large treatment-seeking sample of patients with OCD. Patients completed a battery of self-report measures of OCD and health anxiety symptoms and related cognitive biases. Results from regression analyses indicated that illness anxiety symptoms were associated with harm obsessions and checking rituals, as well as with the tendency to overestimate threat and responsibility for harm. Illness anxiety was not associated with perfectionism. Conceptual and clinical implications of these findings are discussed.
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http://dx.doi.org/10.1016/j.psychres.2017.07.012DOI Listing
October 2017

Anxiety sensitivity as a predictor of outcome in the treatment of obsessive-compulsive disorder.

J Behav Ther Exp Psychiatry 2017 Dec 6;57:113-117. Epub 2017 May 6.

Rogers Memorial Hospital, Oconomowoc, WI, United States.

Background And Objectives: To address the fact that not all individuals who receive cognitive-behavioral therapy (CBT) for obsessive-compulsive disorder (OCD) exhibit complete symptom reduction, research has examined factors that predict outcome; however, no studies have examined anxiety sensitivity (AS) as a predictor of outcome of CBT for OCD. AS refers to the fear of anxious arousal that results from mistaken beliefs about the dangerousness of anxiety-related body sensations. It is important to understand whether AS influences OCD treatment outcome, considering that (a) some obsessions directly relate to AS, and (b) OCD patients with high AS may be reluctant to engage in anxiety-provoking components of CBT for OCD.

Methods: Patients (N = 187) with a primary diagnosis of OCD who received residential CBT for OCD participated in this study, which involved completing a self-report battery at pre- and post-treatment.

Results: Results supported study hypotheses, in that (a) baseline AS positively correlated with baseline OCD severity, and (b) greater baseline AS prospectively predicted higher posttreatment OCD symptom severity even after controlling for pretreatment OCD and depression severity.

Limitations: The study was limited by its use of an older measure of AS, reliance on self-report measures, and nonstandardized treatment across participants.

Conclusions: Findings highlight the importance of AS in the nature and treatment of OCD. Clinical implications and future directions are discussed.
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http://dx.doi.org/10.1016/j.jbtep.2017.05.003DOI Listing
December 2017

Male clinical norms and sex differences on the Eating Disorder Inventory (EDI) and Eating Disorder Examination Questionnaire (EDE-Q).

Int J Eat Disord 2017 07 24;50(7):769-775. Epub 2017 Apr 24.

Department of Psychiatry, University of California, San Diego, La Jolla, California.

Objective: Evidence indicates that males account for a significant minority of patients with eating disorders (EDs). However, prior research has been limited by inclusion of small and predominantly non-clinical samples of males. This study aimed to (1) provide male clinical norms for widely used ED measures (Eating Disorder Examination Questionnaire [EDE-Q] and Eating Disorder Inventory-3 [EDI-3]) and (2) examine sex differences in overall ED psychopathology.

Method: Participants were 386 male and 1,487 female patients with an ED diagnosis aged 16 years and older who completed the EDE-Q and EDI-3 upon admission to a residential or partial hospital ED treatment program.

Results: Normative data were calculated for the EDE-Q (global and subscales) and the EDI-3 (drive for thinness, body dissatisfaction, and bulimia). Analyses of variance (ANOVAs) used to examine sex, ED diagnosis, and their interaction in relation to overall ED psychopathology revealed a consistent pattern of greater severity among females for ED psychopathology.

Discussion: This study provides clinical norms on the EDE-Q and the EDI-3 for males with clinically diagnosed EDs. It is unclear whether the greater severity observed in females reflects qualitative differences in ED presentation or true quantitative differences in ED severity. Additional research examining the underlying nature of these differences and utilizing male-specific ED measures with clinical samples is warranted.
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http://dx.doi.org/10.1002/eat.22716DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5741972PMC
July 2017

An Initial Case Series of Intensive Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder in Adolescents with Autism Spectrum Disorder.

Child Psychiatry Hum Dev 2018 02;49(1):9-19

Department of Pediatrics, University of South Florida, St. Petersburg, FL, USA.

Obsessive-compulsive disorder (OCD) is prevalent among youth with autism spectrum disorder (ASD). Cognitive-behavioral therapy (CBT) with ASD-specific modifications has support for treating OCD in this population; however, use of intensive CBT in youth with ASD and severe OCD has not been tested. The current study examined the preliminary effectiveness of an individualized intensive CBT protocol for OCD in adolescents with ASD. Nine adolescents (aged 11-17 years) completed a regimen of intensive CBT (range 24-80 daily sessions) incorporating exposure with response prevention (ERP). Treatment materials, language and techniques were modified in accordance with evidence-based findings for this population. Seven of nine participants (78%) were treatment responders, and large treatment effects (d = 1.35-2.58) were obtained on primary outcomes (e.g., obsessive-compulsive symptom severity). Preliminary findings suggest that an intensive CBT approach for OCD is effective among adolescents with ASD.
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http://dx.doi.org/10.1007/s10578-017-0724-1DOI Listing
February 2018

Disgust proneness predicts obsessive-compulsive disorder symptom severity in a clinical sample of youth: Distinctions from negative affect.

J Affect Disord 2017 Apr 14;213:118-125. Epub 2017 Feb 14.

Rogers Memorial Hospital, USA.

Background: Although studies have linked disgust proneness to the etiology and maintenance of obsessive-compulsive disorder (OCD) in adults, there remains a paucity of research examining the specificity of this association among youth.

Method: The present study employed structural equation modeling to examine the association between disgust proneness, negative affect, and OCD symptom severity in a clinical sample of youth admitted to a residential treatment facility (N =471).

Results: Results indicate that disgust proneness and negative affect latent factors independently predicted an OCD symptom severity latent factor. However, when both variables were modeled as predictors simultaneously, latent disgust proneness remained significantly associated with OCD symptom severity, whereas the association between latent negative affect and OCD symptom severity became nonsignificant. Tests of mediation converged in support of disgust proneness as a significant intervening variable between negative affect and OCD symptom severity. Subsequent analysis showed that the path from disgust proneness to OCD symptom severity in the structural model was significantly stronger among those without a primary diagnosis of OCD compared to those with a primary diagnosis of OCD.

Limitations: Given the cross-sectional design, the causal inferences that can be made are limited. The present study is also limited by the exclusive reliance on self-report measures.

Conclusions: Disgust proneness may play a uniquely important role in OCD among youth.
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http://dx.doi.org/10.1016/j.jad.2017.02.017DOI Listing
April 2017

Symptom correspondence between clinicians and patients on the Yale-Brown Obsessive Compulsive Scale.

Compr Psychiatry 2017 02 30;73:105-110. Epub 2016 Nov 30.

Rogers Memorial Hospital, Oconomowoc, WI, USA.

The present study examined concordance between the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and its self-report version (Y-BOCS-SR), as well as theoretically derived moderators. Sixty-seven adults (ages 18-67) with obsessive-compulsive disorder (OCD) were administered the Y-BOCS prior to completing self-report measures. The Y-BOCS-SR generated lower scores relative to the clinician-administered Y-BOCS (5.3 points lower). Strong correspondence was shown between the Y-BOCS and Y-BOCS-SR; however, many items exhibited fair to moderate agreement, particularly the resistance and control against obsessions/compulsions items. Depression significantly moderated correspondence such that Y-BOCS-SR scores significantly predicted Y-BOCS scores in the presence of low and average depression levels in our sample, but not for patients with high levels of depression relative to the rest of our sample; gender, generalized anxiety and obsessionality did not significantly impact agreement. Synthesizing the present data, the Y-BOCS-SR demonstrates modest agreement with the Y-BOCS and may underestimate clinical severity especially for those with high levels of depression.
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http://dx.doi.org/10.1016/j.comppsych.2016.11.011DOI Listing
February 2017

Is disgust proneness sensitive to treatment for OCD among youth?: Examination of diagnostic specificity and symptom correlates.

J Anxiety Disord 2016 12 6;44:47-54. Epub 2016 Oct 6.

Department of Psychology, Vanderbilt University, Nashville, TN, USA; Rogers Memorial Hospital, Oconomowoc, WI, USA.

Although disgust proneness has been implicated in obsessive-compulsive disorder (OCD), there is a paucity of research examining change in disgust proneness during treatment as well as the correlates of such change, especially in children. This study examined the relationship between changes in disgust proneness and disorder-specific symptoms during residential treatment among youth with OCD, anxiety, and mood disorders. Youth ages 12-18 (n=472) completed pre- and post-outcome measures of OCD, anxiety, and mood symptoms and disgust proneness. Results indicate that although disgust proneness decreases during treatment for youth with OCD, anxiety, and mood disorders, youth with primary OCD experienced the greatest decrease in disgust proneness over the course of treatment. Reductions in disgust proneness during treatment were significantly correlated with reductions in multiple symptom measures, with the strongest correlations between reductions in disgust proneness and OCD symptoms. Implications and directions for future research are discussed.
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http://dx.doi.org/10.1016/j.janxdis.2016.09.011DOI Listing
December 2016

Further Psychometric Evaluation of the Child Disgust Scale.

Child Psychiatry Hum Dev 2017 02;48(1):32-39

Department of Pediatrics, University of South Florida, Tampa, FL, USA.

This study evaluated the psychometric properties of the Child Disgust Scale (CDS) among 457 youth (ages 8-17, M = 14.77 ± 1.98 years) initiating residential treatment for obsessive-compulsive disorder and anxiety disorders. Confirmatory factor analysis supported a bifactor model with two distinct factors of Disgust Avoidance and Disgust Affect, in addition to an overall General Disgust factor. Strong internal consistency was observed for the CDS total and factor scores. In addition, CDS scores demonstrated generally modest and positive correlations with child-reported obsessive-compulsive and anxiety symptoms, weaker correlations with parent-reported anxiety and child-rated impairment, and non-significant correlations with parent-rated impairment. Findings suggest that the CDS displays strong psychometric properties and is developmentally appropriate for use in pediatric clinical populations with obsessive-compulsive and anxiety disorders.
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http://dx.doi.org/10.1007/s10578-016-0650-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6167059PMC
February 2017

Residential treatment outcomes for adolescents with obsessive-compulsive disorder.

Psychother Res 2016 11 26;26(6):727-36. Epub 2015 Aug 26.

a Rogers Memorial Hospital , Oconomowoc , WI , USA.

Objective: We examined outcomes from a residential treatment program emphasizing exposure and response prevention (ERP) to determine if the typically robust response to this treatment in outpatient settings extends to patients treated in this unique context.

Method: One hundred and seventy-two adolescents with primary Obsessive-compulsive disorder (OCD) completed measures at admission and discharge. Almost all (92.4%) participants had at least two diagnoses and nearly half (44.2%) had three or more. Treatment consisted of intensive ERP (i.e., approximately 26.5 hr per week), additional cognitive behavioral therapy interventions, and medication management within a residential setting. In contrast to the samples reported on in the vast majority of other pediatric OCD trials, participants in the current study were living apart from their families and were immersed within the treatment setting, with staff members available at all times.

Results: Paired sample t-tests revealed significant decreases in OCD and depression severity.

Conclusions: Results suggest that residential treatment for adolescents with OCD using a multimodal approach emphasizing ERP can be effective for complex cases with significant comorbidity. Results were comparable with several randomized controlled trials.
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http://dx.doi.org/10.1080/10503307.2015.1065022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4769131PMC
November 2016