Psychology Topic 5 - Abnormal Psychology - Treatment of Disorders Studies

Issari et al. - Drug Treatment SSRIs (Abnormal Psychology: Biological Treatments)

Aim: To provide evidence to support the use of SSRIs for OCD

Procedure: Researchers performed a meta-analysis of 17 randomised placebo-controlled trials, including over 3000 participants.

Findings: Y-BOCS scores were significantly lower for the SSRI group after just two weeks than for the matched placebo group.

Conclusion: These results suggest that the greatest treatment gains in OCD are seen early in SSRI treatment.

This was a surprising but positive finding, as previous research suggests that SSRIs can take effect slowly.

Critical thinking:

· Effects were reduced over the longer term, but increasing dosages moderated this – could this suggest tolerance?

· Although SSRIs or clomipramine are effective, at least 30% of patients do not show any significant improvement.

· Placebo was used

· Large sample size

Askari et al. - Drug Treatment SARIs (Abnormal Psychology: Biological Treatments)

Aim: To examine the efficacy and tolerability of Granisetron when combined with an SSRI called fluvoxamine for patients with moderate to severe OCD.

Procedure: The sample was recruited from outpatient clinics at two large referral centres in Iran. 39 participants aged 18 to 60 were included in the final analysis. All had Y-BOCS scores of at least 21/40 (moderate symptoms) and reached the threshold for a diagnosis of OCD using the DSM-IV-TR.

Participants were randomly allocated to either the experimental or the control group. Each received 1 mg of either Granisetron or the placebo every 12 hours, in addition to 100mg of fluvoxamine for the first four weeks, increasing to 200mg in the remaining weeks.

Obsessions and compulsions were assessed using the sub-scales of the Y-BOCs, and side effects were monitored using a standardised checklist.

Data were collected at the start of the study (the baseline) and every other week up to and including week 8. It was a double-blind study.

The dependent variable was the extent to which symptoms improved over the 8 weeks, and this was divided into three categories.

· Partial response: a reduction in symptoms of at least 25% on the Y-BOCs

· Complete response: a reduction of at least 35% on the Y-BOCs

· Remission: a Y-BOCS score equal to or less than 16

Findings:

Throughout the 8-week trial:

· The Granisetron group experienced a reduction in symptoms equivalent to 16.8 points on the Y-BOCs, whereas the placebo group only reduced their scores by an average of 9.9 points.

· 100% of the Granisetron group achieved a complete response at 8 weeks, and 90% were in remission compared with only 35% of the placebo (+ SSRI) group.

Week 2: the difference between the Granisetron and placebo groups was not significant

Week 4: the Granisetron group was showing significantly greater improvement than the placebo group, as illustrated in the graph

Tolerability was the same for both groups, suggesting the side effects of Granisetron were no worse than the SSRI on its own.

Conclusion: People with OCD can achieve a faster and greater reduction in symptoms by combining fluvoxamine and Granisetron, with no increase in adverse side effects.

Critical Thinking

· The internal validity of the study was high as the study used random allocation to ensure the reduction in symptoms could not be attributable to participant variables.

· The validity of the participants' OCD diagnosis was carefully checked by two experienced psychiatrists using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I)

· This is a pioneering study, and at the time of publication, it had not been replicated, meaning the reliability of the findings had not been established.

· The study only lasted eight weeks, meaning the longevity of these initial findings is unclear; tolerance may have appeared in the patients being monitored over a longer period, e.g. 12 to 18 months.

· The study included slightly more females than males, and the mean age was mid-thirties, meaning males and younger or older patients may have behaved differently. In addition, the study did not include anyone who had already been classed as treatment-resistant meaning it is unclear whether Granisetron would be helpful for everyone.

· Inter-rater reliability between the four residents responsible for assessing the patients was high ( > 85%), meaning they were generally in agreement with each other's scoring of the Y-BOCs;

· The participants, psychiatrists, residents (in charge of prescribing medications and assessing symptoms), and the statistician who analysed the data were all 'blind', i.e. did not know which groups the participants were in, meaning the results could not be affected by demand characteristics or researcher bias.

Wang et al. - Electroconvulsive Therapy (ECT)(Abnormal Psychology: Biological Treatments)

Electroconvulsive therapy (ECT) is not currently used as a first-line treatment for obsessive-compulsive disorder (OCD). However, several related case reports have demonstrated that ECT seems to be effective for severe OCD, especially when first-line therapies have failed.

Aim: To investigate the effectiveness of ECT for severe OCD

Procedure: Researchers investigated the courses, detailed parameters, effects, and follow-up information relating to three patients with severe OCD treated by modified bifrontal ECT after their first-line anti-OCD treatments, pharmacotherapy, behavioural therapy, and cognitive behavioural therapy failed. The number of ECT procedures administered in each case is as follows: Case 1 = 8; Case 2 = 3; and Case 3 = 4.

Findings: In all three cases, the patient's depressive symptoms improved considerably after the ECT procedures. In addition, the condition of all three patients' OCD significantly improved and remained stable at regular follow-ups.

Conclusion: ECT may play an effective role in treating severe OCD.

Critical thinking

• Case study – small, niche sample size (see the full study for participant details)

• Only for severe cases

Eddy et al. - Exposure Response Prevention (ERP) (Abnormal Psychology: Psychological/Cognitive Treatments)

Aim: To investigate the effectiveness of ERP as a treatment for OCD.

Procedure: Researchers conducted a meta-analysis.

Findings: ERP led to a clinically significant improvement for about 68.8% of participants who completed the program, compared with 56.6% making a comparable level of improvement upon completion of cognitive therapy (CT). However, CT did have a higher recovery rate of 49.8% compared with 38.2% for ERP.

Conclusion: ERP was deemed the most effective in reducing symptoms of the psychological therapies examined in this study. However, those who were able to complete the cognitive therapy treatment were more likely to recover from the disorder.

Critical Thinking:

• There is much empirical support for ERP, which is more effective than other therapies, including relaxation therapy and anxiety management (Hezel and Simpson, 2013).

• It has also been effective across a wide range of treatment settings, including inpatients and outpatients, as well as with people with varying severity of symptoms in various cultures.

• Foa et al. (2005) found that augmenting ERP with medication (e.g. clomipramine) did not improve its success rate. Yet, ERP plus medication was more effective than medication alone, providing further support for the Role of ERP.

• Furthermore, Simpson et al. (2008, 2013) found ERP was more effective in increasing the effects of SSRIs than either stress management training or an additional drug, such as risperidone.

• Despite the positive findings, around 35 - 40% of people with OCD do not recover completely after ERP; this is associated with poor compliance, lack of insight (i.e. not recognising that their thoughts or behaviours are irrational), and comorbid depression. 20 - 30% drop out of treatment because they find it time-consuming and/or too challenging.

Williams & Grisham - Cognitive Bias Modification Therapy (CBM) (Abnormal Psychology: Psychological/Cognitive Treatments)

Aim: To investigate the effectiveness of cognitive bias modification (CBM) in treating OCD.

Procedure: A volunteer sample of 89 adults with intrusive thoughts and/or compulsive behaviours completed a self-report questionnaire measuring the severity of their OCD symptoms. They were then randomly allocated to either the control condition or the positive condition. In the positive condition, all scenarios had positive endings, cueing the participants to anticipate positive outcomes. In the control condition, only half the scenarios had positive endings, meaning participants could not anticipate the ending.

The CBM sessions involved imagining oneself in 164 situations that tapped into the core beliefs in OCD, e.g. overestimation of threat.

For example, "You are riding the bus home from work. The passenger beside you sneezes, so you offer them a tissue. You think to yourself that offering a tissue was a behaviour that was k_nd/ r_sky'.

The participants had to fill in an 'i' to make the word 'kind' (positive condition) or the word 'risky' (control condition).

The researchers measured interpretation bias to see whether the participants changed from a negative to a positive bias following the CBM intervention. The researchers looked at biases relating specifically to core beliefs associated with OCD and a more general positive/negative bias. After the training, they completed the interpretation bias task again, plus three behavioural tasks.

The behavioural tasks

· Thought-action fusion: Participants typed the name of a loved one into a computer; the next screen read: Now imagine that (loved one's name) has been in a car accident. The participant then rated their distress; they were also given the option to delete the sentence.

· Perfectionism: Participants had to write a summary of the procedure for the next participant. They had very little time to do this. They then rated their confidence in their write-up and were asked if they wanted to add any extra detail.

· Contamination: Participants had to clean their keyboard and mouse while being covertly observed. The researchers counted how many disinfectant wipes were used and how long they spent cleaning.

Findings: The researchers found a significant difference in interpretation bias between the positive and control conditions (p < 0.01).

The participants in the positive group exhibited a clear shift from negative to positive bias. Importantly, this shift was only apparent in the rating of the OCD-related sentences but did not apply to the general bias sentences.

This shows that the CBM targeted the core OCD beliefs and not just brought about a general change from negative to positive bias.

Participants also reported less distress and urge to neutralise following the thought-fusion task. Still, there was no difference between the two groups regarding the participants deleting the sentence. Furthermore, there was no significant difference between the two groups on the other behavioural tasks. Participants in the positive condition did not differ from the control group in terms of their confidence in their write-ups, whether they chose to add to their write-ups, how long they spent cleaning, or how many disinfectant wipes they used to clean the keyboard and mouse.

Finally, the researchers report that the severity of the participants' OCD symptoms was not a factor in the efficacy of the intervention.

Conclusion: This research suggests that CBM could be an effective therapy for anyone showing OCD symptoms, mild or severe.

Critical thinking

• Cognitive therapy is usually conducted over several weeks/months, not a single session as with this study. It is impossible to know how effective CBM would be if delivered over a longer period and how long-lasting the effects might have been. For example, the positive bias may have worn off unless 'topped up' again with further CBM sessions. For this study, only short-term effects were measured.

• The behavioural measures may have been ineffective due to poor task design; the tasks may not have picked up more subtle behavioural changes or required more CBM to observe behavioural changes. Furthermore, the tasks were not individualised to the different types of OCD symptoms experienced by the participants.

• The research was not conducted on a clinical sample, i.e. the participants had not received a diagnosis of OCD, so generalisations should be made cautiously. However, the fact that CBM was effective for people with mild and severe symptoms suggests it should be effective for people with a diagnosis.

• In terms of practicality, CBM can be delivered remotely via the Internet or a mobile phone app, providing a cost-effective solution for people who do not have time or cannot afford to see a therapist. As 42% of people with OCD are not currently receiving therapy, research such as this is critical to the wellbeing of a large sector of society.

Amir et al. - Self Directed therapy (sERP)(Abnormal Psychology: Psychological/Cognitive Treatments)

Despite strong evidence to support the efficacy of Exposure Response Prevention (ERP) therapy in reducing OCD symptoms, it requires a highly trained therapist, making it an expensive and inaccessible option for many people. Making ERP more accessible is, therefore, a priority. One possibility is self-directed therapy (sERP). Here the client works through a program designed by a trained therapist, but it is completed independently via computer or mobile phone.

Aim: To examine the effect of combining ERP and Cognitive Bias Modification (CBM), a technique previously shown to help encourage compliance. It also tests the efficacy of a self-directed treatment program for OCD integrating sERP with CBM and explores whether different types of CBM are more effective than others.

Procedure: 22 people (14 male and 8 female) who met the OCD diagnostic criteria participated in a 7-week treatment program.

They were each assessed using the Y-BOCS interview to assess the severity of their symptoms on a scale of 0 - 40. They completed a battery of tests, including the interpretation and attention bias measures. These measures were all taken again at the end of the study to compare scores before and after treatment. In other words, the study used a pre-test/post-test design.

The ERP therapist worked with the clients to create a fear hierarchy by gathering photographs of objects and situations that reflected thoughts and situations associated with their symptoms. The clinician conducted a practice ERP training session with the participants. In addition to the ERP exercises using their hierarchies, they participated in weekly CBM tasks. Tasks were counterbalanced so that everyone completed all five tasks, but the order was varied to eliminate order effects and increase internal validity. The tasks included interpretation bias modification, attention bias modification, attention control, working memory training, and a control task.

Interpretation bias task: A word representing either a threat interpretation (e.g., "dog-poop") or a benign interpretation (e.g., "twig") appears in the centre of the computer screen for 500 ms. Next, an ambiguous sentence (e.g., "I stepped on something brown") appears on the screen, and the computer prompts participants to press a key if they thought the word and sentence were related (agree) or to press another key if they thought the word and sentence were not related (disagree).

· Attention control task: During each trial, a fixation sign (either +,−, or 0) appears for 500 ms, followed by a negative, neutral, or positive word that appears on either the left or right side of the screen for 500 ms. An arrow appears in either the same or opposite location as the word for 16 – 500ms. Participants are instructed to respond with a right or left mouse click indicating the direction of the arrow (pointing up or down).

Over the next five weeks, the participants completed sERP + CBM training sessions at home and in the clinic, where a research assistant observed them. They were told that access to the clinician was for emergencies only, and the research assistant always used standardised instructions. In addition, they completed self-reported measures of their symptoms.

Findings: Only two of the four CBM tasks were significant - the interpretation bias modification and attention control tasks. The control condition showed no improvement.

73% of the sample (16/22) completed the course. All completers significantly reduced their YBOCS scores following treatment, from an average of 29/40 to 16.5/40 (p<0.001). 44% were identified as fully recovered. These positive outcomes were also maintained in a four-month follow-up with average YBOCs was 15/40.

Conclusion: When sERP is augmented with CBM-I, it can have very positive outcomes

Critical Thinking

The study used a pre-test/post-test design - in other words, a repeated measures design - which reduces the effects of participant variability.

Despite the therapy being self-conducted, the sessions were conducted in the presence of a research assistant so that they could be sure that the tasks were completed as expected, thus enhancing internal validity. However, this may have decreased ecological validity and increased compliance. Participants may have felt more motivated to carry out the exercises, as they were doing it as part of a research study in front of a psychologist. The results may have differed if the participants had completed the sERP alone in their own homes.

The study used self-report measures to assess the efficacy of the different augmentation strategies, and participants may have given socially desirable responses, i.e. saying that their symptoms were improved more than they were. This said, the Y-BOCS was used pre and post-intervention, and this is a clinician-based assessment based on a semi-structured interview, providing a slightly more objective view.

The sample size was relatively small, reducing the power of the statistical tests.

The sample was predominantly white Caucasian (15/22). The remainder were primarily Hispanic, with only two identifying as Native American and Other. As with many studies in the field of mental health, people from ethnic minority groups are under-represented, meaning one cannot be sure whether these therapies would be effective in treating people from differing cultural backgrounds.

• This mode of delivery is too challenging for some people; the exposure element is hard, especially in the absence of a reassuring therapist to support and motivate them. This can lead to non-compliance and failure to complete the program. Greist et al. (2002) found a dropout rate of a massive 50% for sERP. For this reason, psychologists are seeking ways of improving the therapy. For example, Najmi and Amir (2010) found that people with contamination-related OCD who completed a program targeting attention bias (CBM-A) completed more steps in their ERP hierarchy than those who did not complete the CBM-A program.

Nicolini - Influence of Culture on OCD and Its Treatment: A Comparative Study (Abnormal Psychology: Sociocultural Approach)

Aims: The study aimed to investigate the influence of cultural diversity on the manifestations of obsessive-compulsive disorder (OCD) and identify factors of cultural diversity that significantly impact OCD symptoms. The study also explored differences among various cultures regarding OCD issues.

Procedures: The researchers reviewed the literature using keywords related to obsessive-compulsive disorder, culture, cultural identity, and religion. The review covered ten years and focused on studies examining the relationship between culture and OCD across different countries and regions.

Findings: The study found that cultural variations in OCD symptoms did not significantly. However, certain cultural factors, such as religion and religiosity, affected the content of obsessions and the severity of manifestations. For example:

1. United States: In the US, where Christianity is prevalent, religious obsessions related to sin, guilt, and morality were frequently reported among individuals with OCD.

2. India: In India, where Hinduism is prominent, obsessions related to purity, pollution, and religious rituals were more common.

3. Saudi Arabia: In Saudi Arabia, where Islam is widely practised, obsessions related to religious rules and rituals, such as cleanliness and prayer, were frequently observed.

The review also highlighted the importance of considering other cultural factors, such as educational background, access to health services, and food, in understanding the influence of culture on OCD and its treatment.

In addition, people of Asian origin are especially prone to unpleasant side effects when prescribed clomipramine, and this has been explained by the prevalence of a specific genetic polymorphism that leads people to become 'slow metabolisers'

Conclusions: The study concluded that cultural diversity does not seem to alter the main symptoms of OCD, suggesting that well-determined pathophysiological mechanisms may influence behaviours related to OCD. However, cultural factors like religion and religiosity can impact the content and severity of OCD symptoms. The researchers emphasised the need to evaluate cultural elements using sensitive investigational instruments to enhance understanding of the Role of culture in OCD and its treatment.

Overall, this study provides insights into the influence of culture on OCD and highlights the importance of considering cultural diversity in understanding and treating the disorder. By recognising cultural factors, healthcare professionals can provide more culturally sensitive and effective interventions for individuals with OCD across different cultural backgrounds.

Critical Thinking

· Comprehensive Literature Review: The study conducted a thorough literature review covering ten years, increasing the findings' reliability and validity. This approach ensures that a wide range of relevant studies are considered, enhancing the comprehensiveness of the research.

· Comparative Approach: By examining OCD across different countries and cultures, the study adopted a comparative approach, allowing for the identification of cultural factors that may influence OCD symptoms. This approach adds depth and richness to understanding culture's Role in OCD.

· Implications for Treatment: The study emphasised the need to consider cultural diversity in treating OCD. By recognising the influence of culture on OCD symptoms, healthcare professionals can develop more culturally sensitive interventions, leading to improved treatment outcomes for individuals from diverse cultural backgrounds.

· Generalisability: The study's findings may have limited generalisability due to the reliance on a literature review. The results are based on the findings of other studies and may not capture the full range of cultural diversity and its influence on OCD symptoms in different populations.

· Potential Bias: Including only studies published within the last ten years may introduce bias by excluding older studies that could provide valuable insights into the cultural aspects of OCD. Additionally, the selection of keywords and the inclusion criteria for the literature review could introduce potential bias and limit the scope of the findings.

· Lack of Primary Data: The study relied solely on existing literature and did not collect primary data. While a comprehensive literature review can provide valuable insights, it may limit the depth of understanding obtained from direct data collection methods such as surveys or interviews.

· Measurement Challenges: The study emphasises the importance of evaluating cultural elements using sensitive investigational instruments. However, it does not provide specific details on the measurement tools used or address potential challenges in assessing cultural factors accurately. Measurement issues can affect the reliability and validity of the findings.

Medeiros et al. - Cross-cultural variations in OCD (Abnormal Psychology: Sociocultural Approach)

Aims: This study aimed to compare individuals with obsessive-compulsive disorder (OCD) from the United States and Brazil to examine potential cross-cultural differences in clinical characteristics and comorbidity patterns.

Comorbidity: The simultaneous presence of two disorders at the same time.

Procedures: The study included 1,187 adult treatment-seeking OCD outpatients, with 236 participants from the United States and 951 from Brazil. Participants were recruited from psychiatric treatment settings and assessed using standardised instruments to gather demographic and clinical data.

Findings: The demographic analysis revealed that individuals with OCD from the United States were older, more likely to identify as Caucasian, had achieved higher education levels, and were less likely to be partnered compared to participants from Brazil. However, the two samples exhibited similar clinical profiles after controlling for demographics. Brazilian participants had higher rates of comorbid generalised anxiety disorder and post-traumatic stress disorder. At the same time, individuals from the United States were more likely to have a lifetime history of addiction, including alcohol use and substance-use disorders.

Conclusions: This study, which represents the largest direct cross-cultural comparison in OCD, found that individuals with OCD from the United States and Brazil shared similar clinical profiles after accounting for demographic differences. However, some notable cross-cultural differences were observed in comorbidity patterns, suggesting that cultural factors may influence the manifestation and comorbidity of OCD. The findings highlight the importance of considering cultural factors in assessing and treating individuals with OCD and emphasise the need for culture-sensitive treatments.

Critical Thinking

· Large sample size: The study included a substantial sample of 1,187 adult, treatment-seeking OCD outpatients, which enhances the generalizability of the findings and increases the statistical power of the analysis.

· Direct cross-cultural comparison: The study directly compared individuals with OCD from the United States and Brazil, allowing for a more accurate assessment of cross-cultural differences than indirect comparisons.

· Standardised assessment instruments: The study utilised standardised instruments to gather demographic and clinical data, improving the findings' reliability and validity.

· Consideration of confounding factors: The study controlled for demographic variables, such as age and educational level, when comparing clinical profiles between the two countries, which helps isolate the cultural influences on OCD.

· Sample selection bias: The participants were recruited from psychiatric treatment settings, which may limit the generalizability of the findings to individuals with OCD who do not seek treatment or receive care in these settings.

· Cultural diversity within countries: The study compared individuals from the United States and Brazil as a whole, but both countries have diverse populations with variations in cultural beliefs and attitudes. The study did not explore potential regional or subgroup differences within each country.

· Cross-sectional design: The study employed a cross-sectional design, which captures data at a single point in time. Longitudinal studies would better understand the stability and progression of OCD symptoms and comorbidity patterns within and across cultures.

· Potential measurement bias: The study relied on self-report measures, which recall biases, social desirability biases, or cultural differences in reporting styles may influence. Objective measures or clinician ratings could have provided additional validity to the findings.

Williams et al. - Barriers to treatment among African Americans with obsessive-compulsive disorder (Abnormal Psychology: Sociocultural Approach)

African Americans are underrepresented in OCD treatment centers and less likely to experience a remission of symptoms.

Aim: To examine the barriers that prevent African Americans with OCD from receiving treatment.

Procedure: 71 adult African Americans with OCD were recruited and administered the modified Barriers to Treatment Participation Scale (BTPS) and the Barriers to Treatment Questionnaire (BTQ).

Findings: Comparing the BTQ between a European American Internet sample (N=108) and the African American OCD sample (N=71) revealed barriers unique to African Americans, including not knowing where to find help and concerns about discrimination.

A Mokken Scale Analysis of the BTPS in the African American participants identified seven major barriers, including the cost of treatment, stigma, fears of therapy, believing that the clinician will be unable to help, feeling no need for treatment, and treatment logistics (being too busy or treatment being too inconvenient).

Significant relationships emerged between age, gender, income, education, insurance status, and ethnic affirmation/belonging among several of the Mokken scales.

A one-way ANOVA demonstrated that concerns about cost were significantly greater for those without insurance, versus those with public or private plans.

Conclusion: Requesting treatment and the fear of shame differs within cultures. It is important to increase cultural competence and educate health professionals in this cultural difference, this could include community education and affordable treatment options.

Critical thinking:

· Only includes one culture

· Doesn’t consider religion

· Recent study – high temporal validity

· Does not state which treatment they were recommended

· Identifies seven barriers but doesn’t give full explanation of why these are barriers

· Reliability and validity of the method - questionnaire