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The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry., Prim Care Companion CNS Disord 2024;26(3):23f03653 ., Author affiliations are listed at the end of this article., (© Copyright 2024 Physicians Postgraduate Press, Inc.)

Background and Objectives: Preliminary findings suggest that acceptance and commitment therapy-informed exposure therapy may be an effective treatment for obsessive-compulsive disorder (OCD). However, there is a lack of experimental studies that have examined immediate effects of acceptance-based strategies during exposure to disorder-relevant stimuli in persons with OCD., Methods: Fifty-three inpatients (64% female) with OCD participated in an experimental study during which they were exposed to obsessive-compulsive washing-relevant pictures and were instructed to either passively view these pictures for 5 s (neutral condition), to accept their feelings (acceptance condition) or to intensify their feelings (exposure condition) for 90 s each., Results: The acceptance condition led to higher acceptance and lower unpleasantness of patients' current feelings compared to the neutral condition and to lower strength of obsessions and urge to perform compulsions but only when compared to the exposure condition. Higher self-reported OCD symptom severity related to higher unpleasantness and strength of obsessions, particularly in the neutral condition., Limitations: Future studies need to test whether the current findings translate to other stimuli and other forms of obsessions and compulsions. Due to the short duration, the exposure condition might have only mimicked the early phase of exposure and response prevention., Conclusions: Acceptance-based strategies during cue exposure immediately increase acceptance of and reduce unpleasant feelings. In line with the rationale of acceptance-based treatment approaches, which do not aim at immediate disorder-specific symptom reductions, effects on obsessions and compulsions may be more delayed or require repeated training sessions., Competing Interests: Declaration of competing interest All authors declare that none of them has a conflict of interest., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Objective . Deep brain stimulation is a treatment option for patients with refractory obsessive-compulsive disorder. A new generation of stimulators hold promise for closed loop stimulation, with adaptive stimulation in response to biologic signals. Here we aimed to discover a suitable biomarker in the ventral striatum in patients with obsessive compulsive disorder using local field potentials. Approach. We induced obsessions and compulsions in 11 patients undergoing deep brain stimulation treatment using a symptom provocation task. Then we trained machine learning models to predict symptoms using the recorded intracranial signal from the deep brain stimulation electrodes. Main results. Average areas under the receiver operating characteristics curve were 62.1% for obsessions and 78.2% for compulsions for patient specific models. For obsessions it reached over 85% in one patient, whereas performance was near chance level when the model was trained across patients. Optimal performances for obsessions and compulsions was obtained at different recording sites. Significance . The results from this study suggest that closed loop stimulation may be a viable option for obsessive-compulsive disorder, but that intracranial biomarkers are patient and not disorder specific. Clinical Trial: Netherlands trial registry NL7486., (Creative Commons Attribution license.)

Visual perspective may have an important role in the phenomenology of intrusive images relevant to psychological disorders such as obsessive-compulsive disorder (OCD). The aim of the current study was to examine the subjective and behavioural effects of manipulating visual perspective, to either field or observer, on intrusive images related to doubting and contamination concerns. One hundred and twelve undergraduate participants with high levels OCD symptoms were asked to identify and imagine an intrusive image related to either doubting or contamination concerns. We then randomly assigned them to re-visualise their image from either a field (first-person) or observer (third-person) visual perspective. Participants shifted towards using an observer perspective demonstrated a greater decrease on ratings of subjective measures of image-related distress, prospective likelihood of the image occurring, and urges to suppress the image, relative to those shifted to a field perspective. In addition, those in the observer perspective evidenced a greater decrease on behavioural indices relevant to OCD, such as reduced frequency of the intrusive image and decreased efforts to neutralise the image. We discuss implications for imagery in OCD., Competing Interests: Declaration of Competing Interest The authors declare no conflicts of interest., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

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.

This article is an attempt at a psychoanalytic understanding of Diogenes syndrome, or hoarding disorder syndrome, by way of a clinical case. This syndrome is characterized by a failure to attend to proper housing habits, including the hoarding of rubbish that may, in fact, create unsuitable, even dangerous, living conditions. The clinical case used suggests that Diogenes syndrome or hoarding disorder reflects or indicates an extreme form of obsessive neurosis involving libidinal regressions to anal fixations designed, paradoxically, to satisfy both a passion for dirty and for order. However, this pathological hoarding may also function to protect the subject against fears associated with meeting people, thereby avoiding any possible intimacy and promoting self-exclusion in an anti-object aim. Finally, the case under discussion helps us to understand the particular psychological aspects or relevance that the actual items and rubbish accumulated have in this syndrome.

Background: The acute effects of aerobic exercise on improved mood and anxiety reduction have been demonstrated across clinical and nonclinical populations. Limited work has evaluated the acute effects of aerobic exercise on negative affect, obsessions, and compulsions in patients with Obsessive Compulsive Disorder (OCD)., Method: Fifty-five patients (64% female) with treatment-resistant OCD were randomized to either 12 weeks of aerobic exercise (AE) or health education contact (HEC) control. Participants rated negative affect (i.e., mood and anxiety), obsessions and compulsions before and after each weekly AE or HEC session. Multilevel models were constructed to evaluate the effect of intervention condition, treatment week (time), and their interaction in terms of acute change in affect, obsession, and compulsions., Results: Results reflected a main effect of condition, such that AE resulted in significantly larger increases in positive mood, and reductions in anxiety and compulsions, as compared to HEC. There was also a main effect of time in predicting acute anxiety reduction, such that linear reductions in anxiety over the course of treatment were observed. No significant effects were observed for acute changes in obsessions., Limitations: The sample was small and was limited in demographic heterogeneity. Bouts of aerobic exercise were not standardized in terms of duration and mode, which could impact affective response to exercise, and acute affective OCD effects were exclusively self-reported., Discussion: The current findings may help elucidate potential mechanisms of action of exercise on OCD outcomes. In addition, these results point toward the potential of designing exercise interventions that can teach patients to utilize individual bouts of physical activity, "in-the-moment" to improve mood and reduce anxiety and compulsions., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Cognitive behavior therapy (CBT) is an effective treatment for obsessive-compulsive disorder (OCD). However, less is known about how obsessions and compulsions change during treatment, either in tandem, sequentially, or independently. The current study used latent difference score analysis to show path-analytic dynamic modeling of OCD symptom change during CBT. Four competing models of the temporal relationship between obsessions and compulsions were examined: no coupling (obsessions and compulsions are not dynamically related), goal directed (obsessions lead to subsequent changes in compulsions), habit driven (compulsions lead to subsequent changes in obsessions), and reciprocal. Treatment seeking participants (N = 84) with a principal diagnosis of OCD completed 12 weeks of CBT group therapy and completed measures assessing obsession and compulsion severity at pretreatment, Sessions 4 and 8, and end of treatment. Bivariate results supported the goal directed traditional CBT model, where obsession scores are temporally associated with subsequent changes in compulsion scores. These results have implications for theoretical and treatment modelling of obsessions and compulsions in OCD treatment., (Copyright © 2018. Published by Elsevier Ltd.)

There is little research on treating symptoms of sexual orientation-obsessive-compulsive disorder (SO-OCD). Semantic networks represent a new cognitive approach for understanding cognitive mechanisms of SO-OCD. Specifically, we tested whether the self-help cognitive technique of association splitting (AS) developed from this approach would be efficacious in reducing SO-OCD symptoms and thought suppression. One hundred and twenty heterosexual undergraduates (82 females, 38 males) were randomly assigned to either the AS or waitlist control group. At baseline and four weeks later, participants completed items assessing SO-OCD symptoms, measures of sexual obsessions and thought suppression, and an association task in which they generated associations to different cue words. Generated associations were coded based on SO-OCD relevance and emotional valence. Results indicated reductions in SO-OCD-relevant associations across levels of emotional valence and SO-OCD-irrelevant negative associations, and increases in SO-OCD-irrelevant positive and neutral associations, only in the AS group. Furthermore, there were reductions in SO-OCD symptoms, sexual obsessions, and thought suppression only in the AS group. Importantly, these findings were obtained with overall large effect sizes. AS appears to be an efficacious self-help technique in reducing SO-OCD symptoms, sexual obsessions, and thought suppression. Clinical implications, limitations, and suggestions for future research are discussed.

Objective: The evidence base for the treatment of morbid jealousy with integrative therapies is thin. This study explored the efficacy of cognitive analytic therapy (CAT)., Design: An adjudicated hermeneutic single-case efficacy design evaluated the cognitive analytic treatment of a patient meeting diagnostic criteria for obsessive morbid jealousy., Method: A rich case record was developed using a matrix of nomothetic and ideographic quantitative and qualitative outcomes. This record was then debated by sceptic and affirmative research teams. Experienced psychotherapy researchers acted as judges, assessed the original case record, and heard the affirmative-versus-sceptic debate. Judges pronounced an opinion regarding the efficacy of the therapy., Results: The efficacy of CAT was supported by all three judges. Each ruled that change had occurred due to the action of the therapy, beyond any level of reasonable doubt., Conclusions: This research demonstrates the potential usefulness of CAT in treating morbid jealousy and suggests that CAT is conceptually well suited. Suggestions for future clinical and research directions are provided., Practitioner Points: The relational approach of CAT makes it a suitable therapy for morbid jealousy. The narrative reformulation component of CAT appears to facilitate early change in chronic jealousy patterns. It is helpful for therapists during sessions to use CAT theory to diagrammatically spell out the patterns maintaining jealousy., (© 2017 The British Psychological Society.)

Experiences with autistic and primitive mental states have significant implications for our understanding of obsessionality. Consequently, obsessionality is seen as an attempt at a massive simplification of experience, in order to deal with the pain inherent in the encounter with intense emotional experience and with the separateness of an enigmatic object that eludes one's omnipotent control. Moreover, early loss and a precocious awareness of separateness often play roles in the withdrawal to obsessional thinking and verbosity, and to an illusion of omnipotent control of the object. Interpretations focusing on conflicting desires, or linking repressed and displaced parts of the personality with the defenses against them, do not reach these patients in a way that facilitates psychic change. An alternative approach, it is suggested, is to work at primitive, nonsymbolic levels of mental functioning, where experience cannot be verbally communicated and dynamically interpreted, but must first be lived in the here and now of the analysis. This is illustrated through the analysis of a person trying to cope with the experience of early loss by deadening emotion and finding shelter in obsessionality.

Unlabelled: Although cognitive interventions for obsessive-compulsive disorder (OCD) have been tested in randomized trials, there are few trials that have tested the specific mechanisms of cognitive interventions, i.e. how they achieve their effects. In this study, we aimed to investigate the mediating effects of a short cognitive intervention in the treatment of OCD and used data from a recently conducted randomized controlled trial where 101 participants were allocated to either Internet-based CBT (ICBT) or to a control condition. Obsessive beliefs were measured at pre-treatment, at the time they had received the cognitive intervention, and also at post-treatment. Weekly OCD symptoms were measured throughout the 10 weeks of treatment. We hypothesized that (1) the ICBT group would have greater reductions in obsessive beliefs (controlling for change in OCD symptoms) after completing the cognitive intervention, and that (2) this reduction would, in turn, predict greater OCD symptom reduction throughout the rest of the treatment period. Contrary to our expectations, the longitudinal mediation analysis indicated that (1) being randomized to ICBT actually increased the degree of obsessive beliefs after receiving the cognitive intervention at weeks 1-3, and (2) increase in obsessive beliefs predicted better outcome later in treatment. However, when repeating the analysis using cross-sectional data at post-treatment, the results were in line with the initial hypotheses. Results were replicated when the control condition received ICBT. We conclude that, although obsessive beliefs were significantly reduced at post-treatment for the ICBT group, early increase rather than decrease in obsessive beliefs predicted favourable outcome., Key Practitioner Message: This study investigated the impact of cognitive interventions on obsessive beliefs for patients with obsessive-compulsive disorder. Results showed that a sudden increase in obsessive beliefs is not an indicator of worse treatment response. On the contrary, it is more likely that the patient is better off when having this sudden increase. Clinicians should not be alarmed if the patient has a sudden increase in obsessive beliefs, but we do recommend the clinician to investigate the reasons for this further., (Copyright © 2014 John Wiley & Sons, Ltd.)

Background and Objectives: A growing body of research has linked high distress intolerance (DI) to obsessions, but not other OCD symptom domains. However, existing research is correlational. Experimental studies are needed, but brief methods for reducing DI are lacking. To address these gaps in the literature, a brief, computerized intervention aimed at reducing DI was developed to determine if changing DI affected obsessional phenomena., Methods: Individuals reporting high DI were randomized to a treatment or waitlist control group (N = 53). Individuals in the treatment group received the DI treatment (i.e., a 2 h computerized intervention) over two weeks, and then underwent a post-assessment in which DI and obsession-relevant phenomena were measured. Individuals in the control group only received the post-assessment., Results: Analyses revealed a greater reduction in self-reported DI on one measure and smaller decreases in behavioral DI in the intervention condition relative to the waitlist condition, as well as lower in-vivo urges to neutralize an intrusive thought; however, anxious reactivity to the intrusion and neutralization behavior were not affected. Further, bootstrapping analyses revealed that reductions in DI mediated the effect of the intervention on neutralization urges., Limitations: A clinical sample and placebo control condition were not used., Conclusions: These results provide experimental evidence for the role of DI in obsessional phenomena, specifically in affecting urges to neutralize intrusions, findings consistent with negative reinforcement models of DI. Further, results revealed that DI can be reduced with a brief, computerized intervention, which has important implications for future experimental research and treatment development., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Case: Chloe is a 9-year-old gal whose mother made an initial visit to a new pediatrician for concerns about her behavior. Chloe is apprehensive about the visit and frequently hides behind her mother.Her parents first noticed Chloe becoming angry and more emotional 3 years ago, which her parents did not initially understand. However, over the past year, she has started to have more worries and unusual behavior.Chloe and her mother report that when she walks through doorways, she will almost always go back and walks through again. At home, she will walk through doorways multiple times and at school, she will pretend she forgot something so her friends do not notice. She often will not walk downstairs and occasionally her mother has to carry her. Clothes are problematic for Chloe. If her father touches something of a specific color and then touches Chloe, she will have to change her clothes or take a shower. Sometimes, she will never be able to wear those clothes again. She had a recent episode where she could not stop tapping a red paper, because if she stopped, she said it would burst into flame. During the 2 weeks before the pediatric visit, symptoms increased to the point that she is now refusing to go to school. When she stays home, she lays in 1 place all day.Chloe is a fourth grade student. The family does not report academic concerns. She has friends. She denies any appetite or sleep problems. She endorses periods of sadness, lack of energy, and decreased interest in social activities, mostly because she worries and is embarrassed. She kept her behaviors hidden from her 5 siblings for the past year, and she talked only to her mother about them. She is worried her friends might discover her behaviors.The family history is notable for multiple paternal family members with anxiety and bipolar disorder and depression on mother's side. A few months ago, Chloe's family adopted a 7-year-old child with special needs from China.Her growth, vital signs, and physical examination are unremarkable. Her mother filled out the Short Mood and Feelings Questionnaire and the Screen for Child Anxiety-Related Emotional Disorders, which both had elevated scores.

Intrusive musical imagery (IMI) consists of involuntarily recalled, short, looping fragments of melodies. Musical obsessions are distressing, impairing forms of IMI that merit investigation in their own right and, more generally, research into these phenomena may broaden our understanding of obsessive-compulsive disorder (OCD), which is phenomenologically and etiologically heterogeneous. We present the first comprehensive review of musical obsessions, based on the largest set of case descriptions ever assembled (N=96). Characteristics of musical obsessions are described and compared with normal IMI, musical hallucinations, and visual obsessional imagery. Assessment, differential diagnosis, comorbidity, etiologic hypotheses, and treatments are described. Musical obsessions may be under-diagnosed because they are not adequately assessed by current measures of OCD. Musical obsessions have been misdiagnosed as psychotic phenomena, which has led to ineffective treatment. Accurate diagnosis is important for appropriate treatment. Musical obsessions may respond to treatments that are not recommended for prototypic OCD symptoms., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

In his analyses of obsessional patients, Sigmund Freud suggested that they suffered from intrusive cognitions and compulsive activities. Early psychoanalysts delineated the phenomenology of obsessionality, but did not differentiate what is currently termed obsessive-compulsive disorder from obsessional personality. However, it was widely recognized that the success of psychoanalysis with obsessional patients was limited due to rigid characterological defences and transference resistances. The present paper examines the case of a middle-aged obsessional academic who had been treated for nearly twenty years in a 'classical' Freudian psychoanalysis prior to entering Jungian analysis. It examines how persistent focus on Oedipal conflicts undesirably reinforced the transference resistance in this obsessional man, and suggests that focusing instead on diminishing the harshness of the super-ego via the therapeutic alliance, and fostering faith in the salutary aspects of unconscious processing has led to salutary results in this case. The biblical book of Job is adopted as ancient instruction in how to address the scrupulosity and addictive mental structuring of obsessionality in analysis., (© 2014, The Society of Analytical Psychology.)

This paper offers a new understanding of disorders as undifferentiated selfobject formations. A treatment example of a multipledisordered patient is presented to illustrate how disorders diminished as a result of this understanding. This paper highlights the developmental importance of the undifferentiated selfobject and suggests that early interruptions of this discovery experience that take place during the infant's positive moments of freedom and enthusiasm are traumatic. If they go beyond the tolerance of the infant, they can be imprinted as unconscious core traumatic experiences. They remain as implicit memories that can act as warnings of repetitions of the trauma that occurred at the time of freedom and enthusiasm in the act of discovering. It can be suggested that the threat of repetitions of the traumatic loss is associated with these positive moments of discovery. This threat directs the needed self-sustaining undifferentiated selfobject discovery experience away from the positive, thereby leaving the posttraumatic effects of the loss as the focus of discovery. This focus leads to destructive preoccupations and obsessions that are considered disorders such as depression, suicidal thinking, self-mutilation, and eating disorders. Once patients understand the importance of the undifferentiated selfobject discovery need, the delinking of the undifferentiated selfobject from the negative preoccupations takes place. As a result, disorders diminish, and patients begin to consider positive possibilities for their lives. This paper suggests that early interferences in the development of the undifferentiated selfobject lead to the formation of disorders. A treatment of a multidisordered patient is presented to illustrate how this understanding was central to the diminishing of the disorders.

Musical obsessions and hallucinations are disturbing experiences of repeating internal music. Antipsychotic medication can sometimes reduce these symptoms but can also trigger or augment them. We report the case of a female patient with schizophrenia with drug-resistant obsessive musical hallucinations. The patient volunteered to participate in a 9-month pilot study to follow the development of the condition using an involuntary music and mood inventory. The patient perceived benefits from the intervention, including reduced anxiety, increased feeling of being in control and understanding the condition better. Findings from this case study suggest that cognitive therapy can be a useful complementary method of care for persons with musical obsessions. The presented tool requires further investigations among those with this rare condition.

Although obsessive jealousy is a highly disturbing disorder, frequently it goes unrecognized, as most attention is paid to delusional jealousy, being the more prominent clinical phenomenon. In order to distinguish obsessive from delusional jealousy, the basic clinical characteristics of these two types of jealousy are presented, as well as the mechanism of their respective genesis, and the differences which we must be aware of in order to prevent misdiagnosis and consequent wrong treatment choices. The theoretical considerations are supported by case presentations providing a clear picture of the phenomena discussed. Unlike delusional jealousy, characterized by the presence of strong, false beliefs that the partner is unfaithful, individuals with obsessive jealousy suffer from unpleasant and irrational jealous ruminations that the partner could be unfaithful, accompanied by compulsive checking of partners' behaviour, which is recognised by the patient as ego-dystonic. This jealousy resembles obsessive-compulsive phenomenology more closely. Despite the differences, both forms of jealousy result in significant distress for patients and intimate relationships, and carry the risk of abuse, homicide and/or suicide. Delusional jealousy is a psychotic disorder and should be treated mainly with antipsychotics, while obsessive jealousy resembles obsessive-compulsive disorder and should be treated with SSRIs and cognitive-behavioural therapy. Regardless of the presence or absence of insight into the disorder, one of the key factors in the treatment of pathological jealousy is to motivate the sufferers for pharmacological and psychotherapeutic interventions.

The present study was designed to assess the psychometric properties of the Brazilian version of the Obsessive Beliefs Questionnaire (OBQ-44) in 104 patients with obsessive compulsive disorder (OCD) at the Hospital de Clínicas de Porto Alegre. The secondary objective was to ascertain whether a decline in OBQ-44 scores occurs after cognitive-behavioral group therapy (CBGT). Factor analysis identified three dysfunctional belief domains from the original scale. Internal consistency and reproducibility were very good and good, respectively. Sensitivity to treatment change (cognitive-behavioral group therapy) was good, and pre-post intervention standardized effect sizes (Cohen's d) were strong. The OBQ-44 plays an important role in this setting; as a user-friendly, self-administered instrument that lists the most common dysfunctional beliefs of OCD patients, it enables healthcare providers to assess whether their patients' beliefs change after treatment., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Objective: We explored the dynamic relationship between cognition and obsession severity during 2 different treatments for primary obsessions, examining evidence for the hypothesis that symptom reduction would be mediated by appraisals about the meaning of unwanted intrusive thoughts., Method: Data from a recent randomized controlled trial were analyzed with traditional mediation analyses and latent difference scores. The trial had compared cognitive behavioral therapy and stress management training among 73 patients with primary obsessions. Mediation analyses were conducted with pre-, post-, and follow-up scores on the Obsessions subscale of the Yale-Brown Obsessive Compulsive Scale and 2 self-report measures of cognitions related to obsessive-compulsive disorder. Bivariate dual change score (BDCS) analyses were conducted with weekly assessments of obsession severity and appraisals of personal significance., Results: Change in most cognitions related to obsessive-compulsive disorder accounted for reduction in obsession severity during the course of treatment and follow-up. BDCS analyses of the longitudinal data, however, indicated prior obsession severity is a leading indicator of subsequent change in appraisals, rather than the reverse. Analyses also suggested cognitive behavioral therapy is more effective than stress management training when symptoms are severe and that stress management training is more advantageous in the context of mild-to-moderate obsessions., Conclusions: The traditional mediation analysis indicated that appraisal change is a tenable mediator of obsession reduction, but the BDCS results raise doubts about the causal direction. The results highlight the importance of examining the dynamic relationship between putative mediators and outcome variables, and they suggest interesting hypotheses about mechanisms in treatment of obsessions.

In this paper the author explores the clinical significance of the presence of a depressed internal object in a patient with marked obsessional features, dominating the patient's internal world and restricting relations in external life. After discussing important aspects of the contribution of Freud and later writers to the study of obsessional neurosis, the author provides clinical material that shows the patient's tormented relationship to a feared depressed object that was manifested in the transference. Developing her argument, the author suggests that if the analyst does not fully grasp the primitive anxieties of the underlying state of mind she can be prone to enter into an aggressive enactment with the patient's sadistic superego. This kind of enactment may arouse excitement and triumph in the patient, but actually confirms his doubts and fears about the capacity of his object to contain him., (Copyright © 2011 Institute of Psychoanalysis.)

Background: Guilt appears to be a factor that may increase the severity of obsessive-compulsive disorder (OCD) and negatively impact treatment outcomes. However, researchers and clinicians have paid little attention to addressing guilt in OCD treatment. Because guilt is an important perpetuating and mediating factor for OCD symptoms and the development of guilt-specific strategies may yield improved treatment outcomes, we hypothesized that a review of the relevant literature may provide important guidance for the field., Methods: To identify existing scientific contributions across psychological, biologic, and theological disciplines, we conducted a systematic review of the literature on the topic of pathological guilt (PG) in OCD., Results: Fourteen studies focusing on both PG and OCD were identified. The content of these papers consistently reflected the theme that guilt plays a significant role in OCD and obsessive-compulsive symptoms., Conclusions: The potential influence and moderating effects of guilt require more focused attention in the clinical management of OCD. Development of routine standardized measures and treatment protocols targeting the role of guilt in OCD, in addition to consultation with clergy or other appropriate community resources, would provide valuable contributions to the literature. Addressing this affective component related to OCD may lead to improved treatment outcomes and fewer relapses for this debilitating and frequently chronic illness.

Jealousy is a powerful emotional force in couples' relationships. In just seconds it can turn love into rage and tenderness into acts of control, intimidation, and even suicide or murder. Yet it has been surprisingly neglected in the couples therapy field. In this paper we define jealousy broadly as a hub of contradictory feelings, thoughts, beliefs, actions, and reactions, and consider how it can range from a normative predicament to extreme obsessive manifestations. We ground jealousy in couples' basic relational tasks and utilize the construct of the vulnerability cycle to describe processes of derailment. We offer guidelines on how to contain the couple's escalation, disarm their ineffective strategies and power struggles, identify underlying vulnerabilities and yearnings, and distinguish meanings that belong to the present from those that belong to the past, or to other contexts. The goal is to facilitate relational and personal changes that can yield a better fit between the partners' expectations., (2010 © FPI, Inc.)

The earliest descriptions of obsessive-compulsive disorder (OCD) were religious, as was the understanding of their origins. With the emancipation, religion in OCD was relegated to its status today: a less common symptom of OCD in most Western societies known as scrupulosity. The frequency of scrupulosity in OCD varies in the literature from 0% to 93% of cases, and this variability seems predicated on the importance of religious belief and observance in the community examined. Despite the similarities between religious ritual and compulsions, the evidence to date that religion increases the risk of the development of OCD is scarce. Scrupulosity is presented as a classic version of OCD, with obsessions and compulsions, distress, and diminished functioning similar to those of other forms of OCD. The differentiation between normal religiosity and scrupulosity is presented, and the unique aspects of cognitive-behavioral therapy in treating scrupulosity, especially in religious populations, are reviewed.

This study provides data about the differential effectiveness of cognitive therapy (CT) for obsessive-compulsive disorder (OCD) symptom presentation. Two OCD manifestations, autogenous and reactive, are considered. Seventy OCD patients started CT; 81.40% completed it and 72.85% were available 1 year later. Fifteen of the 57 treatment completers had autogenous obsessions, whereas 33 had reactive obsessions. Nine patients had both obsession modalities. Reactive patients were more severe, as they scored higher on thought suppression and on the dysfunctional beliefs of intolerance to uncertainty and perfectionism. Autogenous patients scored higher on the over-importance of thoughts beliefs. Although CT was effective in reducing OCD severity and the ascription to dysfunctional beliefs and neutralizing strategies in both the autogenous and the reactive patients, a significantly better outcome was observed for the autogenous patients, both at post-treatment (with 73.33% recovering versus 33.33% for reactives) and 1 year later., ((c) 2010 Elsevier Ltd. All rights reserved.)

Like most human behaviors, saving and collecting possessions can range from totally normal and adaptive to excessive or pathological. Hoarding, or compulsive hoarding, are some of the more commonly used terms to refer to this excessive form of collectionism. Hoarding is highly prevalent and, when severe, it is associated with substantial functional disability and represents a great burden for the sufferers, their families, and society in general. It is generally considered difficult to treat. Hoarding can occur in the context of a variety of neurological and psychiatric conditions. Although it has frequently been considered a symptom (or symptom dimension) of obsessive-compulsive disorder, and is listed as one of the diagnostic criteria for obsessive-compulsive personality disorder, its diagnostic boundaries are still a matter of debate. Recent data suggest that compulsive hoarding can also be a standalone problem. Growing evidence from epidemiological, phenomenological, neurobiological, and treatment studies suggests that compulsive hoarding may be best classified as a discrete disorder with its own diagnostic criteria.

This study tested Rachman's cognitive behavioral method for treating obsessions not accompanied by prominent overt compulsions. The cognitive behavioral treatment was compared to waitlist control and an active and credible comparison of stress management training (SMT). Of the 73 adults who were randomized, 67 completed treatment, and 58 were available for one-year follow-up. The active treatments, compared to waitlist, resulted in substantially lower YBOCS scores, OCD-related cognitions and depression as well as improved social functioning. Overall, CBT and SMT showed large and similar reductions in symptoms. Pre-post effect sizes on YBOCS Obsessions for CBT and SMT completers was d = 2.34 and 1.90, respectively. Although CBT showed small advantages over SMT on some symptom measures immediately after treatment, these differences were no longer apparent in the follow-up period. CBT resulted in larger changes on most OCD-related cognitions compared to SMT. The cognitive changes were stable at 12 months follow-up, but the differences in the cognitive measures faded. The robust and enduring effects of both treatments contradict the long-standing belief that obsessions are resistant to treatment., (2009 Elsevier Ltd. All rights reserved.)

This case study describes how the ACT model was adapted to treat anxious and obsessive thoughts in a young person with moderate/severe learning disabilities. Using mindfulness and ACT-based experiential activities, the client learned to notice her thoughts and distance herself from their literal content. The negative impact that the client's anxious thoughts had on her life was reduced and she was able to return to a part-time college course. The article describes how the client engaged with some ACT-based activities, such as mindfulness and defusion exercises. The outcome suggests that the experiential, activity-based nature of ACT may offer a more accessible intervention model for learning disabled people than traditional CBT models based on verbal reasoning skills. However, the intervention also required considerable individual adaptation and it is likely that this will be the case in work with people with learning disabilities.

Body image disturbance is considered a core characteristic of eating disorders and body dysmorphic disorder (BDD), however its definition has been unclear within the literature. This study examined the multidimensional nature of body image functioning among individuals with either anorexia nervosa (AN; n=35), bulimia nervosa (BN; n=26), or BDD (n=56), relative to female (n=34) and male (n=36) psychiatric controls. Participants were recruited from 10 treatment centers in the United States and England and completed psychometrically validated and standardized self-report measures of body image. Overall, the AN, BN, and BDD groups were characterized by significantly elevated disturbances in most body image dimensions relative to their gender-matched clinical controls. There was variability, however, in the comparisons among the three groups of interest, including foci of body dissatisfaction and body image coping patterns. On omnibus indices of body image disturbance and body image quality of life, patients with BDD reported more body image impairment than those with eating disorders. Although AN, BN, and BDD are characterized by body image disturbances, similar and partially distinctive cognitive, behavioral, and emotional elements of body image functioning exist among these groups. The study's empirical and clinical implications are considered.

This paper discusses the structure and function of the trait of perfectionism within the obsessive personality, and how it dovetails with other features of that style. The author proposes a nuclear adaptive/defensive "myth of perfection" and delineates the phenomenology and clinical presentations of four problematic aspects of perfectionism: inhibitions, over concern with thoroughness and details, difficulty with decisions and commitments, and pickiness. The paper also discusses how several aspects of the obsessive style can present typical difficulties in doing therapy with perfectionists.

Abstract Pornography, if understood to involve the depiction of sexual activity, organs, and experiences, is perhaps as old as human civilization itself. Historically linked to various technological innovations, pornography viewing in the Internet age has reached epic proportions, with large numbers of individuals taking advantage of ease of access, affordability, and presumed anonymity to explore sexual material online. Within the mental health professions substantial research exists on the effects of viewing general pornography; however, the distinctive effects of the marriage of pornography and cyberspace is only beginning to be examined. In addition to reviewing some historical and statistical material about pornography and the relevant psychiatric and psychoanalytic literature, four detailed clinical vignettes are presented to illustrate the types of problems related to Internet pornography use that are being presented to practicing psychotherapists.

Compulsive cybersex has become a significant problem for many men and women who have fallen prey to the accessibility, affordability, and anonymity of online sexual behaviors. Some patients develop problems with compulsive cybersex due to predisposition or accidental conditioning experiences. Other compulsive users of cybersex present with underlying trauma, depression, or addiction. Three case studies highlighted obsession, compulsion, and consequence in the pathogenesis of compulsive cybersex. While men and women differ somewhat in their use of cybersex, both genders exhibit maladaptive coping, conditioned behavior, dissociative reenactment of life trauma, courtship disorder, intimacy dysfunction, and addictive behavior. Comprehensive treatment of compulsive cybersex would include the following components: relapse prevention, intimacy enhancement, lovemap reconstruction, dissociative states therapy, arousal reconditioning, and coping skills training. Thanks to recent treatment advances in several fields, help is available for those caught in the dark side of the net.

The current study reports a case series examining (1) the variation in strength of obsessional doubt and belief in consequences of the doubt; and (2) the interaction between these cognitive components and symptom measures of duration and severity of obsessive-compulsive disorder (OCD), over 24 weeks of cognitive behaviour therapy. Eight participants diagnosed with OCD, four with contamination-related rituals and four with checking behaviours, were selected on the basis of the Yale-Brown obsessive-compulsive scale (Y-BOCS) and Padua ratings. All participants completed daily diaries measuring strength of principal obsessional doubt (0-100), strength of belief in consequences of the doubt (0-100) and the duration of the compulsive rituals throughout the 24 weeks of therapy. Severity of symptomatology was measured pre- and post-treatment using the Y-BOCS. Change in all measures was analysed over time following the procedure outlined by Storchheim and O'Mahoney (2006). Results showed that decrease in belief in secondary consequences is always accompanied by a decrease in strength of obsessions, but the converse does not hold. Furthermore, change in OCD symptomatology may precede cognitive changes., (Copyright (c) 2008 John Wiley & Sons, Ltd.)

Gastroenterologists are often faced with the diagnostic problem of differentiating acute symptoms of ulcerative colitis from functional intestinal disorders. Bowel obsession syndrome (BOS) is an OCD-like, functional syndrome characterized by fear of fecal incontinence and compulsive behaviors of evacuation-checking. Only sparse case studies on treatment of BOS with antidepressants have been published. This is the first study on successful psychotherapy of a male patient with ulcerative colitis overlapping functional bowel symptoms and marked symptoms of BOS. Clinical recognition of BOS may help clinicians in differential diagnosis, prevent unnecessary investigations, and give patients the most appropriate treatment.

After a descriptive phenomenological sketch, we try to elucidate the structure of the "as if" experience. This experience is concerned with appearance, with what 'seems' to a person as opposed to actual reality. Normally there is always the possibility of error trying to recognize reality, which is accessible to anybody. In contrast, for the individual no error is possible regarding an appearance which is accessible to nobody but the person to whom it appears. In daily life we are often unaware of the confusions of reality and appearance. The obsessive patient cannot permit himself such customary confusions. The delusional patient cannot realize relevant confusions of reality and appearance, in spite of encounters with outside persons. As mentioned, reality and appearance get pathologically entangled in both obsessive and delusional patients. Some therapeutic proposals are offered from the standpoint of these "as if" patents.

This article reviews empirical findings on two key premises of the appraisal model of obsessive-compulsive disorder (OCD): (a) non-clinical populations experience intrusive thoughts (ITs) that are similar in form and in content to obsessions; and (b) ITs develop into obsessions because they are appraised according to dysfunctional beliefs. There is support for the universality of ITs. However, the samples used are not representative of the general population. IT measures do not relate systematically or exclusively to OCD symptom measures, and are not specific enough to exclude other types of intrusive thoughts such as negative automatic thoughts or worries, nor are they representative of all types of obsessions. When general distress is controlled, there is so far no evidence that participants with OCD endorse obsessive belief domains more strongly than anxious participants, and inconclusive evidence that OCD and non-clinical samples differ on the belief domains. Some OCD symptom subtypes are associated with belief domains. Currently, there is no coherent model to offer strong predictions about the specificity of the empirically derived belief domains in OCD symptom subtypes. Cognitive therapy based on the appraisal model is an effective treatment for OCD, although it does not add to the treatment efficacy of behaviour therapy. It is unclear how appraisals turn ITs into obsessions. Implications for future research are discussed.

This paper describes a psychotherapeutic constructivist intervention oriented to the resolution of implicative dilemmas, in order to promote personal change. It presents a clinical case study of a client with depression and with some dependent and obsessive functioning. The Repertory Grid Technique was administered along with symptom assessment (SCL-90-R) both at beginning and end of the psychotherapeutic process. Exploring themes emerged from Repgrid, several narratives, experiential and metaphoric strategies were used in order to explore and reconstruct meanings associated with the five implicative dilemmas found. The therapeutic process succeeds at solving dilemmas as found in the post-therapy assessment. This resolution was accompanied by symptom reduction. In conclusion, the utility of implicative dilemmas as a marker to understand the therapeutic impasse and dysfunctional system coherence is discussed, as well as the efficacy of the strategies used in this clinical case concerning its adaptation to working with implicative dilemmas that prevent therapeutic process.

The vengeful state of mind, the conscious psychological component of scenarios of vengefulness, is here seen as a fixation that is instigated and held in place by the workings of hidden shame dynamics, which in extreme cases transform a prodromal disorganized shame state into a relentlessly vengeful state of mind. That state of mind, since it vilifies the offender and disconnects the avenger-offender relationship from the avenger's other relationships to those in the moral and social order, is a manifestation of splitting. Shame-rage cycles, described and investigated by Lewis and her followers, are discussed: unacknowledged or bypassed shame triggers rage, of which vengefulness is one example. Psychoanalytic elaboration of Lewis's insights includes the elaboration of unconscious shame fantasies by virtue of which anticipated shame becomes unbearable. Triggering of rage by unacknowledged shame is an indication of underlying splitting. Clinical material is presented to illustrate the connection between vengeful rage and underlying shame and the resolution of splitting once the underlying shame is acknowledged and becomes bearable. Working through of the vengeful state of mind involves the resolution of splitting, often through an identification that increases the bearability of underlying shame. Forgiveness is seen as the working through of that splitting and as an important feature in the working through of vengefulness.

Objective: To investigate the clinical therapeutic effects of point-stimulation for obsession., Methods: Sixty cases of obsession were divided into two groups: a control group of 30 cases treated with chlorimipramine (Chl), and a treatment group of 30 cases treated by point-stimulation (PS) plus chlorimipramine (PS+Chl). The therapeutic effects and side-effect were evaluated according tb the criteria set in Yale-Brown Obsession Scale (Y-BOCS), Hamilton's depression scale (HAMD), brief psychiatric rating scale (BPRS) and treatment emergent symptom scale (TESS)., Results: The cure rate and markedly effective rate were respectively 26.7% and 56.6% in the control group, and 43.3% and 50% in the treatment group, suggesting that the therapeutic effect in the treatment group was better than that in the control group. The incidence of adverse side-effects was 73.33% in the control group and 46.67% in the treatment group, with a significant difference between the two groups (P<0.05)., Conclusion: Point-stimulation plus small dose of chlorimipramine was superior to the simple chlorimipramine treatment, indicating that the combined method was more effective and safe for obsession with less side effects.

The urge to collect is a ubiquitous phenomenon which has anthropological, sociobiological and individual psychodynamic roots, but occurs far more frequently among men than women. The author examines the reasons for this gender difference and defines systematic collecting to distinguish it from addictive, obsessive and messy collecting, and from related phenomena such as perversion. The mode of collecting and choice of object are important indicators as to the unconscious psychodynamics of a collector and offer opportunity to describe his structural level. Collecting ranges across a broad spectrum, from an ego-syntonic integrated mode, i.e. sublimation, to a neurotic defence against pre-oedipal or oedipal traumas and conflicts. Alongside this drive-theoretical approach, object and Kleinian theory are also applied to the understanding of collecting. Collecting represents a specific form of object relating and way of handling primary loss trauma, which is different from addiction, compulsion, or perversion. Under certain circumstances collecting can also result in a successful Gestalt or way of life. The paper concludes with a case study showing how collecting develops from a pre-oedipal to a more integrated oedipal mode during the course of the analysis, which is reflected in changes in the transference.

The present study investigates the effectiveness of a 3-h cognitive behavioral workshop for individuals, ages 18-22, with subclinical obsessions and compulsions. It was hypothesized that, compared to individuals in an assessment-only waitlist group (n = 42), individuals assigned to the workshop group (n = 43) would experience a significant decrease in obsessive-compulsive (OC) symptomatology, comorbidity, and thought action fusion endorsement at 1-month and 5-month follow-up assessments. An additional outcome of interest was the number of incident cases of obsessive-compulsive disorder (OCD) over the course of the study. The results indicated that the workshop group reported a significantly fewer number of OC symptoms at 5-month follow-up and endorsed significantly less thought action fusion at both follow-up points. However, there were no differences between groups in severity of OC symptoms and number of comorbid diagnoses endorsed. Only one incident case of OCD was observed during the study, from a participant in the waitlist group. These results are discussed in reference to treatment of subclinical anxiety symptoms.

Background: Shared psychotic disorder (folie à deux) is an uncommon entity reported mainly in the context of delusions. Obsessions and compulsions occur very rarely as shared psychopathology., Material and Methods: We present two sisters who manifested shared obsessive-compulsive disorder., Results: Both sisters were managed in keeping with their shared obsessive-compulsive disorder leading onto a similar pattern of response., Conclusions: Shared obsessions could represent the continuum concept of obsessions and delusions, and their relationship needs to be evaluated in greater detail.