Obsessive-compulsive disorder (OCD) is relatively common (Ruscio, Stein, Chiu, & Kessler, 2010) and leads to significant functional impairment (World Health Organization, 2001). Research suggests that exposure and response prevention (EX/RP) is efficacious for reducing OCD symptoms (NICE, 2006); however, standard outpatient EX/RP does not effectively alleviate symptom severity among a substantial proportion of OCD patients (Abramowitz, 2006). Intensive EX/RP programs have been developed to address the needs of treatment-refractory OCD patients (Veale et al., 2016). While evidence from effectiveness studies suggests that intensive EX/RP programs lead to significant reductions in OCD symptom severity, a portion of patients do not demonstrate improvement in response to intensive treatment (e.g., Björgvinsson, Hart, et al., 2013; Boschen, Drummond, & Pillay, 2008). These findings underscore the need to identify reliable predictors of OCD patient response to intensive EX/RP to help target clinical and research efforts toward improving treatment outcomes for those least likely to respond to current treatment modalities. Therefore, the proposed study evaluated distinct trajectories of OCD symptom change across six-weeks of intensive treatment and examined factors that predict membership in those trajectory groups. Results suggested that three latent subgroups of OCD patients emerged with one demonstrating symptom relapse during intensive treatment. Further, OCD symptom severity was the only baseline factor that predicted latent-class membership. Implications and future directions of research are discussed.

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Anemia is a significant public health issue that affects a great number of people in developed and developing countries. The World Health Organization states when the Hb value is/dL in an adult male and/dL in a nonpregnant female, the individual is considered as anemic. Iron deficiency is one of the most common causes of anemia. Inadequate intake of iron, chronic blood loss, and/or a combination of both factors typically lead to iron deficiency anemia. In developed countries, chronic blood loss from gastrointestinal, genitourinary, and gynecological sources are the most common etiologies of iron deficiency anemia. Although there are reports of iron deficiency anemia leading to self-inflicted skin excoriation, there are few cases of chronic blood loss from skin excoriation resulting in severe iron deficiency anemia. We present a 49 year old female with significant past medical history of depression, anxiety and chronic back pain who presented after she was found to have profound anemia with hemoglobin of 4.1g/dl. During interviewing, she denied hematuria, hemoptysis, hematochezia, and had been without menstrual cycles for the past year. Urinalysis was negative for blood as well as two documented negative fecal occult blood tests. Iron studies completed showed severely reduced iron levels. Upon further interviewing, the patient reported a supposedly self-diagnosed keratin disorder. For the past ten years she has been self-treating the keratin disorder by applying topical tretinoin and then wrapping it in saran wrap. She would then peel off areas of skin over multiple areas of her body including all extremities and her face. Multiple pictures of bloody piles of tissue were shown. The patient required 3 units of packed red blood cells and was started on iron supplementation. Gastroenterology was consulted and agreed there was no GI source of her blood loss. Psychiatry further evaluated the patient and diagnosed her with obsessive-compulsive disorder with somatic delusions. The prevalence of anemia among chronic psychiatric patients is more frequent than general population. This coexistence deteriorates the quality of life of the patients, prolongs the psychiatric treatment period, and could even cause an increase in morbidity and mortality. Treatment-related factors, drugs taken, physical conditions, negative lifestyle habits, and nutritional disorders are the reasons for anemia among chronic psychiatric patients. Even though iron deficiency anemia in developed country is most often caused by chronic blood loss from gastrointestinal, genitourinary, and gynecological causes, it is important to evaluate for other factors when none of these are present. Psychiatric causes when warranted from history including somatic delusions from obsessive-compulsive disorder should be considered on the differential when other etiologies are less clear.

Hoarding is characterized by (a) the persistent difficulty discarding personal items; (b) clutter that interferes with living areas; and (c) significant distress or functional impairment. Hoarding symptoms often emerge in childhood and adolescence, yet very few studies on hoarding in this age group exist. Current models of hoarding emphasize impairments in decision-making, yet the literature on decision-making processes in hoarding presents inconsistent findings. Preliminary cognitive studies in adults suggest that hoarding may be associated with deficits in value attribution (the tendency to assign value to personal items). Thus, we propose that the Endowment Effect (EE), in which ownership of an item increases its perceived value, may be informative for the study of hoarding symptoms. This study investigated the EE in youth (children and adolescents) with Obsessive-Compulsive Disorder (OCD) and hoarding symptoms. Given that hoarding involves significant difficulty discarding personal items, we hypothesized that hoarding in youth is associated with a higher EE. Thirty youth participants with a confirmed DSM-5 diagnosis of OCD completed the Endowment Task, a game script of the EE; the Wisconsin Card Sorting Test (WCST), a test of cognitive flexibility; and the Balloon-Analogue Risk Task (BART), a test of risky decision-making. The Children’s Saving Inventory-Parent Version (CSI) was used to measure severity of hoarding symptoms. We divided our sample into thirds based on CSI scores to create a ‘High Hoarding’ group (HH; n=12; mean CSI (S.D.)=30.83 (5.47446)) and a ‘Low Hoarding’ group (LH; n=10; mean CSI (S.D.)=5.00 (3.16228)). The HH group demonstrated a higher average EE than the LH group (average EE, 3.22 and 1.59, respectively). In contrast, no significant between-group differences were found on the WCST and the BART (t=0.901, p=0.378 and t=0.338, p=0.739, respectively). The results of this thesis suggest that psychological ownership plays an important role in the manifestation of hoarding symptoms. Thus, we propose that hoarding might be associated with a specific decision-making deficit related to personal possessions. / Thesis / Master of Science (MSc)

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The prevalence rate for Obsessive-Compulsive Disorder (OCD) is between 0.8% to 2%. Many of these individuals experience scrupulosity or religious obsessive-compulsive disorder. Although scrupulosity is a salient theme for those who suffer from OCD, there is limited amount of research on scrupulosity across cultures. Research is particularly limited in relation to individuals from Latin American countries, including Mexico. In response to this limitation, the purpose of this study is to determine if there is a significant difference in symptoms of scrupulosity in non-referred samples of college students from the U.S. and Mexico. Results indicated that scrupulosity is a valid and reliable construct in the Mexican sample, not different in structure or intensity relative to an American sample.

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Objectives: The first objective of this research was to examine whether symptom dimensions in obsessive-compulsive disorder (OCD) are associated with unique neuropsychological performance profiles. The second objective of this research was to further understand the strengths and weaknesses of two models of symptom dimensions in OCD from a quantitative perspective—conventional subtyping by overt symptom, and the core dimensions model. Finally, the third objective of this research was to investigate the efficacy and treatment acceptability of a cognitive remediation program targeting neurocognitive deficits associated with OCD. Methods: Study 1 reviewed critically studies describing the assessment of differences in neuropsychological functioning between symptom dimensions of OCD, the results of which informed succeeding studies examining: i) the characterization of symptom dimensions in OCD and; ii) the remediation of neuropsychological domains commonly affected in OCD. Accordingly, study 2 compared the suitability of two common statistical approaches, factor analysis and cluster analysis, commonly used in the existing literature to define symptom dimensions based on responses collected from the industry-standard symptom questionnaire, the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), in characterizing symptom dimensions in OCD. Neuropsychological task data were then used to examine the validity of an alternative model of symptom dimensions in OCD (Study 3). Finally, we conducted a feasibility study (Study 4) examining the use of an established cognitive remediation protocol, Goal Management Training (GMT), to target the deficits in neurocognitive function identified in the preceding studies. Results: Much of the existing literature on neuropsychological task performance differences between symptom dimensions of OCD is limited by methodological issues, primarily those concerning methods for defining symptom dimensions. Here, a comparison of the two most common methods for defining dimensions revealed that neither cluster analysis nor factor analysis produced conceptually meaningful subgroups. By exemplifying differences in neuropsychological task performance between those with harm avoidance and those with incompleteness symptoms, however, concrete evidence was provided to support the core dimensions model of OCD. Pilot data point towards the feasibility and efficacy of GMT as a cognitive remediation program for OCD. Conclusions: Pursuing the definition of meaningful, distinct symptom dimensions of OCD is not recommended with the combination of current statistical practices and symptom measures. The early evidence presented here shows promise for the validity of the core dimensions model. Preliminary evidence suggests that the neuropsychological impairments observed in this population, although subtle, may be effectively addressed using Goal Management Training. / Thesis / Doctor of Philosophy (PhD)

The need for effective treatments and treatment accessibility for obsessive-compulsive disorder (OCD) in childhood is evident given that as many as 50% of individuals with OCD report symptom onset before age 15. Despite the growing evidence supporting the efficacy of Exposure and Response Prevention (ERP) for youth with OCD, children seeking services for their OCD symptoms often do not receive ERP. Intensive treatment programs may be a feasible treatment option for children and their families who do not have access to ERP treatment and/or live in an area where therapists trained in ERP are limited. Preliminary studies have shown initial promise for 5-day intensive treatment programs, which have collapsed one-month intensive programs into an even shorter duration. This study serves as the first controlled, one-week intensive intervention for pediatric OCD. To evaluate the efficacy, feasibility, and acceptability of this brief, one-week intensive ERP program for pediatric OCD, nine children with OCD were randomized to a one-week, two-week, or three-week baseline period in a single-case, non-concurrent multiple baseline experimental design. Although symptoms were relatively stable during the baseline period, most participants showed reductions in OCD symptoms with the implementation of treatment. Treatment gains were maintained at a 3-month follow-up assessment; 67% of children were considered treatment responders. Children and families perceived the program to be acceptable, feasible, and beneficial. This study provides support for the efficacy and feasibility of a 5-day intensive treatment program for pediatric OCD. / Ph. D.