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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. (Contains 2 footnotes, 4 tables, and 3 figures.)

Contemporary cognitive treatment of obsessive-compulsive disorder (OCD) dates back to 1985, and rests on the premise that infrequent unwanted intrusions are essentially universal. As such, it is not the intrusion that is the focus of treatment but rather the interpretation or appraisal placed upon the intrusion. A number of cognitive domains are thought to be key areas, including inflated responsibility, overimportance of thoughts, need to control thoughts and overestimation of threat. Cognitive treatment of OCD is idiographic owing in part to the heterogeneous nature of the disorder as well as the cognitive domains implicated in the etiology and maintenance of the disorder. Cognitive treatment of an individual with ego-dystonic sexual and aggressive intrusions is illustrated in the current manuscript. Video clips are embedded at key moments during the treatment to ideally facilitate the illustration of this complex treatment. It is hoped that the addition of video clips will aid in the dissemination of this treatment that was recently tested and found to produce large effect sizes in a recent randomized controlled trial. (Contains 2 figures and 1 table.)

There is a rich theoretical literature on the automatic nature of fear and anxiety and the role of maladaptive fear schemata. Information processing biases, both implicit and explicit, have been demonstrated among clinically anxious persons, but the clinical applications of this work have not been well developed. This article highlights empirical support for implicit cognition in anxiety (evaluating evidence for biases in attention, interpretation, memory, and automatic associations) and then focuses on the relevance of this research for clinical practice. Potential mechanisms for change in implicit cognition are outlined. Although clinical applications for implicit cognition are not yet well articulated, there is good reason to stay tuned to this research because recent advances in the study of automatic fear processing have potential to lead to better assessment and intervention techniques and better prediction of vulnerability to the onset and return of anxiety.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.brat.2005.05.005 Byline: Bethany A. Teachman (a), Sheila R. Woody (b), Joshua C. Magee (a) Keywords: Obsessions; Appraisals; Implicit associations; OCD; Intrusive thoughts Abstract: To evaluate cognitive theories of obsessions, the current study experimentally manipulated appraisals of the importance of intrusive thoughts. Undergraduate students (N=156) completed measures of obsessive-compulsive disorder (OCD) symptoms and beliefs and were primed with a list of commonly reported unwanted thoughts. Participants were then informed that unwanted thoughts are either (1) significant and indicative of their personal values, or (2) meaningless, or participants (3) received no instructions about unwanted thoughts. Participants then completed implicit and explicit measures of self-evaluation and interpretations of their unwanted thoughts. Results indicated that the manipulation shifted implicit appraisals of unwanted thoughts in the expected direction, but not self-evaluations of morality or dangerousness. Interestingly, explicit self-esteem and beliefs about the significance of unwanted thoughts were associated with measures of OCD beliefs, whereas implicit self-evaluations of dangerousness were better predicted by the interaction of pre-existing OCD beliefs with the manipulation. Results are discussed in terms of divergent predictors of implicit and explicit responses to unwanted thoughts. Author Affiliation: (a) Department of Psychology, University of Virginia, P.O. Box 400400, Charlottesville, VA 22904-4400, USA (b) Department of Psychology, University of British Columbia, Canada Article History: Received 27 September 2004; Revised 28 April 2005; Accepted 20 May 2005

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.brat.2005.02.006 Byline: Nicole M. Dorfan, Sheila R. Woody Keywords: Fear reduction; Disgust; Cognition; OCD; Looming vulnerability Abstract: Prominent models of fear focus on the role of cognition in the development and maintenance of maladaptive responses. Little research, however, has evaluated the impact of cognition on distress reduction. The current study uses an experimental design to examine the effect of different types of imagery (moving harm, static harm, and safety) on reduction of distress associated with a contaminating stimulus in a normal university sample. Results indicate that use of moving harm imagery sensitizes distress during a 30-min exposure, whereas static harm and safety imagery reduce distress. These findings demonstrate that cognitive factors can moderate affective response during exposure. Clinical implications for the treatment of anxiety disorders are discussed. Author Affiliation: Department of Psychology, University of British Columbia, 2136 West Mall, Vancouver, BC, Canada V6T 1Z4 Article History: Received 11 August 2004; Revised 18 February 2005; Accepted 22 February 2005

This study evaluates the cognitive model of anxiety by investigating treatment-related changes in automatic associations to evaluate schematic processing. Spider-phobic participants (n = 31) and healthy controls (n = 30) completed fear-based Implicit Association Tests (IATs), which are reaction-time measures that tap implicit associations without requiring conscious introspection. The specific tasks involved classifying pictures of snakes and spiders along with semantic categorizations (good vs. bad, afraid vs. unafraid, danger vs. safety, and disgusting vs. appealing). Phobic individuals were assessed before and after group-based exposure treatment and 2 months later; controls were assessed at matched time points. Results supported clinical applications for implicit fear associations, including prediction of phobic avoidance, and treatment sensitivity of the fear- and disgust-specific automatic associations.

Previous research on the role of therapeutic alliance in cognitive behavioral interventions has shown mixed results. Building on the suggestion that the trajectory of the therapeutic relationship may be more predictive of outcome than simple level of alliance, we examined therapeutic alliance, group cohesion, and homework compliance over the course of treatment for 53 socially phobic clients involved in cognitive-behavioral group therapy. Working alliance increased in a linear fashion over the course of treatment, particularly for clients with social fears limited to public speaking. Homework compliance declined linearly, while group cohesion remained static. Curvilinear models did not explain additional variance beyond the linear terms. Notably, treatment outcome was not significantly related to the development of alliance or decline in homework compliance.

For those with social phobia, self-focused attention has been linked with impairment in social performance, increased social anxiety, and a higher frequency of self-critical thoughts during social situations. The purpose of this investigation was to assess correlates of changes in situational self-focus over the course of cognitive-behavioral treatment (CBT). Focus of attention was assessed after in-session role-plays and after in vivo homework assignments during group CBT for social phobia. Analyses revealed a significant decrease in self-focused attention over time; focus on events and stimuli outside of the self remained unchanged. Treatment gains on anxiety during dyadic interactions, on negative self-judgments, and on personalized social fears were related to reduction in self-focused attention. Those with public speaking phobias showed a strong relationship between decreased self-focus and speech anxiety. These findings suggest that changes in self-focused attention during the course of CBT are related to important therapeutic gains. Specific interventions aimed at decreasing self-focus may be a useful treatment strategy.