Discrimination and symptoms of obsessive-compulsive disorder among African Americans

A network analysis of mechanisms of change during exposures over the course of intensive OCD treatment

Exposure and response prevention (ERP) is an evidence-based treatment for obsessive-compulsive disorder (OCD). Theories for how it works vary in their emphasis on active mechanisms of change. The current study aimed to clarify mechanisms of change in ERP for OCD using network analysis, comparing ERP networks at the start and end of intensive treatment (partial hospital and residential). In our sample of 182 patients, the most central node in both networks was engagement with exposure, which was consistently related to greater understanding of ERP rationale, higher willingness, and less ritualization, accounting for all other variables in the network. There were no significant differences in networks between the start and end of treatment. These results suggest that nonspecific parameters like facilitating engagement in exposures without ritualizing and providing a clear rationale to clients may be key to effective treatment. As such, it may be useful for clinicians to spend adequate time underscoring the need to eliminate rituals to fully engage in exposure tasks and explaining the rationale for ERP prior to doing exposures, regardless of theoretical orientation. Nonetheless, findings represent group-level statistics and more fine-grained idiographic analyses may reveal individual-level differences with respect to central mechanisms of change. Other limitations include demographic homogeneity of our sample.

A pilot study of experiencing racial microaggressions, obsessive-compulsive symptoms, and the role of psychological flexibility

BACKGROUND

Experiencing racial microaggressions has clear effects on physical and psychological health, including obsessive-compulsive disorder symptoms (OCS). More research is needed to examine this link. Psychological flexibility is an important process to examine in this work.

AIMS

This study aimed to examine if, while controlling for depression and anxiety, experiences of microaggressions and psychological flexibility helped explain OCD symptoms within a university-affiliated sample (undergraduate, graduate and law students). This was a pilot exploration of the relationships across themes.

METHOD

Initial baseline data from a longitudinal study of psychological flexibility, OCD symptoms, depression, anxiety and experience of microaggressions was utilized. Correlations and regressions were utilized to examine which OCD symptom dimensions were associated with experiencing racial microaggressions in addition to anxiety and depression, and the added role of psychological flexibility was examined.

RESULTS

OCD symptoms, experiences of microaggressions and psychological flexibility were correlated. Experiences of racial microaggressions explained responsibility for harm and contamination OCD symptoms above and beyond psychological distress. Exploratory results support the relevance of psychological flexibility.

CONCLUSION

Results support other work that experiences of racial microaggressions help explain OCS and they add some support for psychological flexibility as a relevant risk or protective factor for mental health in marginalized populations. These topics should be studied longitudinally with continued consideration of all OCD themes, larger sample sizes, intersecting identities, clinical samples, and continued exploration of psychological flexibility and mindfulness and values-based treatments.

Racial discrimination and 12-month and lifetime anxiety disorders among African American men and women: Findings from the National Survey of American Life

BACKGROUND

The purpose of this study was to assess the associations between racial discrimination and 12-month and lifetime DSM-IV anxiety disorders among African American men and women.

METHODS

Data was drawn from the African American sample of the National Survey of American Life (N = 3570). Racial discrimination was assessed with the Everyday Discrimination Scale. 12-month and lifetime DSM-IV outcomes were any anxiety disorder, posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), panic disorder (PD), social anxiety disorder (SAD), and agoraphobia (AG). Logistic regressions were utilized to assess the relationships between discrimination and anxiety disorders.

RESULTS

The data indicated that racial discrimination was associated with increased odds for 12-month and lifetime anxiety disorders, AG, and PD and lifetime SAD among men. Regarding 12-month disorders among women, racial discrimination was associated with increased odds for any anxiety disorder, PTSD, SAD, and PD. With respect to lifetime disorders among women, racial discrimination was associated with increased odds for any anxiety disorder, PTSD, GAD, SAD, and PD.

LIMITATIONS

The limitations of this study include the utilization of cross-sectional data, self-reported measures, and the exclusion of non-community dwelling individuals.

CONCLUSIONS

The current investigation showed that African American men and women are not impacted by racial discrimination in the same ways. These findings suggest that the mechanisms through which discrimination operates among men and women to influence anxiety disorders is potentially a relevant target for interventions to address gender disparities in anxiety disorders.

Anxiety-Related Disorders in the Context of Racism

PURPOSE OF REVIEW

The literature on racism and anxiety-related disorders, especially social anxiety, specific phobia, and generalized anxiety disorder, is notably lacking. This report aims to review recent evidence demonstrating the link between racial discrimination and various anxiety-related disorders.

RECENT FINDINGS

Anxiety-related disorders were the most significant mediator for daily discrimination and suicidal thoughts, above both depression and substance use. Further, studies showed that racial discrimination promotes posttraumatic stress and racial trauma among people of color. Systemic racism puts people of color at a higher risk for anxiety disorders than White people. Clinical case examples provide lived evidence of diverse racial and ethnic individuals suffering from anxiety-related disorders, with the development and worsening of symptoms due to racism and microaggressions. There is a prominent need for recent research on anxiety-related disorders and racism. Recommendations for clinicians and future research directions are provided. These actions are required to address bias and mental health inequities and empower people of color.

Does the network structure of obsessive-compulsive symptoms at treatment admission identify patients at risk for non-response?

Exposure and response prevention is the gold-standard treatment for obsessive compulsive disorder (OCD), yet up to half of patients do not adequately respond. Thus, different approaches to identifying and intervening with non-responders are badly needed. One approach would be to better understand the functional connections among aspects of OCD symptoms and, ultimately, how to target those associations in treatment. In a large sample of patients who completed intensive treatment for OCD and related disorders (N = 1343), we examined whether differences in network structure of OCD symptom aspects existed at baseline between treatment responders versus non-responders. A network comparison test indicated a significant difference between OCD network structure for responders versus non-responders (M = 0.19, p = .02). Consistent differences emerged between responders and non-responders in how they responded to emotional distress. This pattern of associations suggests that non-responders may have been more reactive to their distress by performing compulsions, thereby worsening their functioning. By examining the association between baseline distress intolerance with other symptom aspects that presumably maintain the disorder (e.g., ritualizing), clinicians can more effectively target those associations in treatment.

Examination of Outcomes among Sexual Minorities in Treatment for Obsessive-Compulsive and Related Disorders

The first-line psychological treatment for obsessive-compulsive and related disorders (OCRDs) is exposure and response prevention (ERP). As the first study to examine treatment outcomes for sexual minorities, it is crucial to examine: (1) how treatment-seeking individuals who identify as sexual minorities compare to heterosexual individuals in symptom severity at admission, length of stay in treatment, and (2) whether ERP is equally effective for sexual minorities. The current study explored these questions in an intensive/residential treatment (IRT) program for OCRDs. Adult participants (N = 191) completed self-reported measures of OCD severity, distress tolerance, and depression at program admission, in the first four weeks of treatment, and at discharge. No differences were found between groups for treatment outcome, although slight differences (non-significant) emerged at baseline for OCRD severity, distress tolerance, and depression. Sexual orientation was not predictive of OCRD severity at weeks 1-4, and number of days spent in treatment was not associated with sexual orientation. This is the first study exploring whether sexual orientation is predictive of treatment outcomes for individuals diagnosed with OCRDs. Results suggest that outcomes did not differ and participation in the program resulted in an overall improvement of symptoms regardless of sexual orientation, however several study limitations are discussed. Future studies should replicate these findings, attempt to collect a larger sample, incorporate qualitative feedback from treatment, and examine outcomes in gender minorities.

Psychiatric, Substance Use, and Structural Disparities Between Gay and Bisexual Men with Histories of Childhood Sexual Abuse and Recent Sexual Risk Behavior

Sexual minority men disproportionately experience childhood sexual abuse (CSA) compared to heterosexual men, resulting in greater risk of psychiatric and substance use diagnoses, sexual risk taking, and HIV acquisition later in life. However, little is known about psychiatric and substance use disparities between gay and bisexual men who have experienced CSA. We recruited a purposive convenience sample in Boston and Miami, involving self-report and clinical interview data from 290 sexual minority men (M age = 38.0 years) who reported CSA, defined as unwanted sexual contact before 13 years of age with an adult or person five years older, or unwanted sexual contact between 13 and 16 years of age with a person 10 years older (or any age with the threat of force or harm). We compared those who self-identified as gay (n = 199) versus bisexual (n = 64) on demographic and structural variables (i.e., government benefits, unstable housing, and neighborhood crime) as well as psychiatric and substance use diagnoses. Across 15 unique diagnoses, three were more common in bisexual men than gay men in unadjusted models: bipolar disorder (OR = 2.90, 95% CI: 1.01-8.34), obsessive compulsive disorder (OR = 2.22, 95% CI: 1.01-4.88), and alcohol use disorder (OR = 1.86, 95% CI: 1.03-3.38). Bisexual men were also more likely to meet criteria for "any substance use disorder" than were gay men (OR = 1.99, 95% CI: 1.10-3.59). However, when race, education, and income were included as covariates, the odds ratios reduced significantly (bipolar disorder: aOR = 1.98, 95% CI: 0.59-6.61; obsessive compulsive disorder: aOR = 1.56, 95% CI: 0.64-3.77; alcohol use disorder, aOR = 1.54, 95% CI: 0.80-2.98; any substance use disorder, aOR = 1.79, 95% CI: 0.93-3.45, respectively). Our results highlight the mental health needs, including problematic substance use, of bisexual men with histories of CSA, as well as the importance of accounting for potential confounding demographic variables that may influence disparities in mental health and substance use.

Knowledge and competency standards for specialized cognitive behavior therapy for adult obsessive-compulsive disorder

Obsessive-Compulsive Disorder (OCD) is a leading cause of disability world-wide (World Health Organization, 2008). Treatment of OCD is a specialized field whose aim is recovery from illness for as many patients as possible. The evidence-based psychotherapeutic treatment for OCD is specialized cognitive behavior therapy (CBT, NICE, 2005, Koran and Simpson, 2013). However, these treatments are not accessible to many sufferers around the world. Currently available guidelines for care are deemed to be essential but insufficient because of highly variable clinician knowledge and competencies specific to OCD. The phase two mandate of the 14 nation International OCD Accreditation Task Force (ATF) created by the Canadian Institute for Obsessive Compulsive Disorders is development of knowledge and competency standards for specialized treatments for OCD through the lifespan deemed by experts to be foundational to transformative change in this field. This paper presents knowledge and competency standards for specialized CBT for adult OCD developed to inform, advance, and offer a model for clinical practice and training for OCD. During upcoming ATF phases three and four criteria and processes for training in specialized treatments for OCD through the lifespan for certification (individuals) and accreditation (sites) will be developed based on the ATF standards.

Cultural competency in the treatment of obsessive-compulsive disorder: practitioner guidelines

This article provides clinical guidelines for basic knowledge and skills essential for successful work with clients who have obsessive-compulsive disorder (OCD) across ethnic, racial and religious differences. We emphasise multiculturalist and anti-racist approaches and the role of culture in shaping the presentation of OCD in clients. Several competencies are discussed to help clinicians differentiate between behaviour that is consistent with group norms versus behaviour that is excessive and psychopathological in nature. Symptom presentation, mental health literacy and explanatory models may differ across cultural groups. The article also highlights the possibility of violating client beliefs and values during cognitive behavioural therapy (CBT), and subsequently offers strategies to mitigate such problems, such as consulting community members, clergy, religious scholars and other authoritative sources. Finally, there is a discussion of how clinicians can help clients from diverse populations overcome a variety of obstacles and challenges faced in the therapeutic context, including stigma and cultural mistrust.

Key learning aims

(1)

Correlates of Obsessive-Compulsive Symptoms Among Black Caribbean Americans

Despite the rapid growth of the Black Caribbean population in the United States, we know little about the presentation and prevalence of obsessive-compulsive disorder (OCD) among these groups. This study examines the demographic correlates and the effect of racial discrimination on OCD symptoms among a nationally-representative sample of Black Caribbean and African American adults (n = 5,191). Drawing on the Composite International Diagnostic Interview Short Form (CIDI-SF) for OCD, we examine two types of obsessions (harm and contamination) and four types of compulsions (repeating, washing, ordering, and counting). There we no significant differences between Black Caribbeans and African Americans in obsessions and compulsions. Analysis among Black Caribbeans found that compared with Jamaican and Trinidadian Americans, Haitian American individuals reported the fewest number of obsessions and compulsions. We show that Black Caribbean Americans with lower income, lower self-rated physical and mental health, and more experiences with racial discrimination report higher levels of OCD. More specifically, racial discrimination was associated with contamination and harm obsessions, as well as washing and repeating compulsions. Our findings highlight the need to consider specific domains of OCD relative to Black Caribbeans, and the relationship between social and demographic variables on symptomology.

Association Splitting for Obsessive-Compulsive Disorder: A Systematic Review

Background:

Association splitting is a cognitive technique that targets obsessions in obsessive-compulsive disorder (OCD) by weakening biased semantic associations among OCDrelevant concepts.

Objective:

In this systematic review, we examine studies on the efficacy of association splitting for reducing OCD symptoms.

Methods:

Following PRISMA guidelines, six studies were included, with diversity in sample characteristics, mode of administration (i.e., self-help vs therapist-assisted), language of administration, comparator groups, etc.

Results:

Results indicated that association splitting, as a self-help intervention, was efficacious in reducing overall OCD symptom severity, specific OCD symptoms (i.e., sexual obsessions), subclinical unwanted intrusions, and thought suppression, with small-to-large effect sizes (e.g., across relevant studies, ds = .28-1.07). Findings were less clear when association splitting was administered on a therapist-assisted basis as an add-on to standard cognitive-behavior therapy (CBT). Nonetheless, across studies, the majority of participants reported high acceptability, ease of comprehension, and adherence to daily association splitting practice.

Conclusion:

Although association splitting is an efficacious and acceptable self-help intervention for OCD symptoms, future studies should include appropriate comparison groups, conduct longitudinal assessments, examine efficacy for different symptom dimensions, and assess changes in semantic networks as proof of mechanistic change. There should also be greater representation of marginalized groups in future studies to assess association splitting’s utility in circumventing barriers to face-to-face CBT. Ethical considerations are also discussed.

Microaggressions: Clarification, Evidence, and Impact

In a 2017 article in Perspectives on Psychological Science, Scott Lilienfeld critiqued the conceptual basis for microaggressions as well as the scientific rigor of scholarship on the topic. The current article provides a response that systematically analyzes the arguments and representations made in Lilienfeld’s critique with regard to the concept of microaggressions and the state of the related research. I show that, in contrast to the claim that the concept of microaggressions is vague and inconsistent, the term is well defined and can be decisively linked to individual prejudice in offenders and mental-health outcomes in targets. I explain how the concept of microaggressions is connected to pathological stereotypes, power structures, structural racism, and multiple forms of racial prejudice. Also described are recent research advances that address some of Lilienfeld’s original critiques. Further, this article highlights potentially problematic attitudes, assumptions, and approaches embedded in Lilienfeld’s analysis that are common to the field of psychology as a whole. It is important for all academics to acknowledge and question their own biases and perspectives when conducting scientific research.

Everyday discrimination among formerly homeless persons in permanent supportive housing

Experiences of discrimination are associated with poor health and are particularly common among persons experiencing homelessness. Permanent supportive housing (PSH) provides a foundation for improved well-being among persons with homelessness histories, but research on discrimination among this population is lacking. We examined changes in experiences of, and perceived reasons for, everyday discrimination when persons moved into PSH. 421 adults in Los Angeles County completed baseline (pre-housing), 3-, 6- or 12-month post-housing structured interviews. Generalized linear mixed models (GLMM) examined change in discrimination outcomes, controlling for demographic characteristics. Everyday discrimination experiences decreased significantly when persons moved from homelessness into PSH, and remained consistently lower across the first year in PSH. Reports of homelessness/poverty, race/ethnicity, and neighborhood as reasons for discrimination also decreased from baseline levels. PSH may offer respite from everyday discrimination, but the persistence of discrimination and particularly racism in society requires structural solutions addressing implicit bias and systemic inequities.

Anxiety, Stress, and Trauma Symptoms in African Americans: Negative Affectivity Does Not Explain the Relationship between Microaggressions and Psychopathology

Prior research has demonstrated a clear relationship between experiences of racial microaggressions and various indicators of psychological unwellness. One concern with these findings is that the role of negative affectivity, considered a marker of neuroticism, has not been considered. Negative affectivity has previously been correlated to experiences of racial discrimination and psychological unwellness and has been suggested as a cause of the observed relationship between microaggressions and psychopathology. We examined the relationships between self-reported frequency of experiences of microaggressions and several mental health outcomes (i.e., anxiety [Beck Anxiety Inventory], stress [General Ethnic and Discrimination Scale], and trauma symptoms [Trauma Symptoms of Discrimination Scale]) in 177 African American and European American college students, controlling for negative affectivity (the Positive and Negative Affect Schedule) and gender. Results indicated that African Americans experience more racial discrimination than European Americans. Negative affectivity in African Americans appears to be significantly related to some but not all perceptions of the experience of discrimination. A strong relationship between racial mistreatment and symptoms of psychopathology was evident, even after controlling for negative affectivity. In summary, African Americans experience clinically measurable anxiety, stress, and trauma symptoms as a result of racial mistreatment, which cannot be wholly explained by individual differences in negative affectivity. Future work should examine additional factors in these relationships, and targeted interventions should be developed to help those suffering as a result of racial mistreatment and to reduce microaggressions.