Overvalued ideas and their impact on treatment outcome

Idéias supervalorizadas e seu impacto no resultado do tratamento

artigos originais

Overvalued ideas and their impact on treatment outcome

Idéias supervalorizadas e seu impacto no resultado do tratamento

Fugen A. Neziroglu¹, Kevin P. Stevens¹ e Jose A. Yaryura-Tobias¹

RESUMO

INTRODUÇÃO: A existência de idéias superestimadas (IS) em pacientes com transtorno obsessivo-compulsivo (TOC) vem sendo teoricamente relacionada a resultado insatisfatório do tratamento. Como até o momento não existem medidas quantitativas das idéias superestimadas, a relação entre IS e resultado fica restrita ao campo hipotético. Houve algumas tentativas de avaliações simples. Era pedido aos pacientes que avaliassem a intensidade de suas convicções, em uma escala de 1 a 10. A seguir, fazia-se a avaliação clínica da fixidez das convicções de 1 a 5, e os pacientes eram classificados segundo o item 11 (insight) da Escala Yale-Brown de Sintomas Obsessivo-compulsivos (Y-BOCS). A proposta deste estudo era determinar a relação existente entre IS, gravidade dos sintomas do TOC e melhora.

MÉTODO: Vinte pacientes com DOC participaram do estudo. Todos eles foram submetidos ao tratamento de prevenção de exposição e reação (PER), durante seis dias por semana, com sessões de 90 minutos, e medicados com inibidores seletivos de recaptação de serotonina. Os medicamentos não foram alterados durante o curso do tratamento. Antes de entrar no estudo, todos os pacientes já recebiam tratamento medicamentoso há, pelo menos, três meses. As escalas de avaliação usadas foram Escala de Idéias Superestimadas (OVIS), Y-BOCS, Inventário Beck para Depressão e Inventário Beck para Ansiedade.

RESULTADOS: Os resultados indicaram que idéias superestimadas não se correlacionavam necessariamente com a gravidade dos sintomas, medidos pela Y-BOCS. Quanto maior o grau medido pela OVIS, menor era a variação na Y-BOCS.

CONCLUSÃO: Idéias superestimadas parecem ser um importante fator de predição de um resultado insatisfatório para o tratamento.

DESCRITORES

Escala de idéias superestimadas; transtorno obsessivo-compulsivo; TOC; predição; resultado do tratamento

ABSTRACT

BACKGROUND: The presence of overvalued ideas (OVI) in patients with obsessive-compulsive disorder (OCD) has been theoretically linked to poorer treatment outcome. However, to date there have not been any quantitative measures of overvalued ideas. Therefore, the relationship between OVI and outcome has been primarily hypothetical. Rudimentary assessments have been attempted by asking patients to rate their strength of belief from 1 to 10, clinically rating the fixity of beliefs from 1 to 5, and rating patients on item 11 (insight) on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS). The purpose of this study was to determine the relationship between OVI, degree of severity of OCD symptoms, and improvement.

METHOD: Twenty patients with OCD participated in the study. All patients were treated with six days a week of 90 minutes of exposure and response prevention (ERP) and selective serotonin re-uptake inhibitors. No changes in medication were made during the course of treatment and all patients had been on their respective medications for at least three months prior to entering the study. Assessment scales consisted of the Overvalued Ideas Scale (OVIS), Y-BOCS, Beck Depression Inventory, and the Beck Anxiety Inventory.

RESULTS: The results indicated that overvalued ideas did not necessarily correlate with severity of symptoms on the Y-BOCS. The higher the score on the OVIS, the less change on the Y-BOCS score.

CONCLUSION: Overvalued ideas appear to be an important predictor of poor outcome.

KEYWORDS

Overvalued ideas scale; obsessive-compulsive disorder; OCD; prediction; treatment outcome.

Introduction

Overvalued Ideas and their Impact on Treatment Outcome Obsessive-compulsive disorder (OCD) is a major psychiatric disorder that affects approximately 2.5% of the general population¹. The disorder affects males and females equally² and is known to persons of all socio-economic strata^3,4. Although definitions and theoretical underpinnings on OCD have changed over time, clinical observations have been recorded with marked consistency^5,6. The major symptoms include obsessions, compulsions and doubting as well as secondary symptoms such as depression, anxiety and severe social and occupational dysfunction. The treatments of choice for OCD involve behavior therapy (exposure and response prevention), and psychopharmacology (SSRI's, clomipramine), which may be used in conjunction and sometimes synergistically.

DSM-IV⁷ currently defines obsessions as repetitive thoughts, images or ideas that are experienced as intrusive and unwanted. Compulsions are defined as ritualistic and repetitive mental or motor acts that are typically, but not necessarily, functionally related to the obsessions. Phenomenologically, the symptoms of OCD are often viewed as senseless and yet uncontrollable.

The most recent revision of DSM, however, provides the diagnostic marker "with poor insight" to identify those persons diagnosed with OCD who view their symptoms as sensible and reasonable. "Poor insight" has been referred to as "overvalued ideation" in the literature⁸ and has been studied for decades. Wernicke⁸ regarded overvalued ideas as misperceptions that are affect driven. The resultant affect activation narrows and focuses attention, making it difficult for individuals to shift attentional sets, which leads to impaired judgment. Jaspers⁹ regarded overvalued ideas as beliefs or cognitions held by individuals to an extreme degree, as is seen in religious or political fanatics, which are resistant to modification even in the face of contradictory evidence. Kozak and Foa¹⁰ regard overvalued ideas as lying on a continuum between rational thoughts and delusional beliefs. Persons diagnosed as OCD with poor insight are seen as individuals whose obsessions may resemble delusional beliefs as the overvalued ideas intensify.

Overvalued Ideas have been reported in spectrum disorders other than OCD such as Body Dysmorphic Disorder, Hypochondria, and Somatoform Disorders¹¹. Although some reports indicate that persons with overvalued ideas improve following intensive treatment^12,13, other reports indicate that treatment often fails or is not as effective when patients harbor overvalued ideas^14-16 or that exposure and response prevention is not as effective as medications in the presence of overvalued ideas¹⁷.

Overvalued ideas, which comprise perceptual aberrations, dysfunctional affective qualities and impaired cognitive processes in general, translate into obsessive symptoms of OCD which are held as reasonable and realistic in particular. Overvalued ideas may prove to represent a segway into shared psychotic symptomatology in persons with OCD¹⁸. Overvalued ideas have been linked to treatment outcome and are seen theoretically as a poor prognostic indicator in the treatment outcome for OCD^19,20. Although a few studies have tentatively shown this relationship, no studies have been conducted to date that replicate these findings while also quantitatively assessing the degree of OVI. Attempts at measuring insight, which is one aspect of OVI, have been limited to item 11 on the Y-BOCS, dichotomously assessed overvalued ideas based on clinical criteria²¹, and a scale developed by Lelliot, Noshirvani and Basoglu¹⁶ assessing fixity, bizarreness, resistance and controllability of compulsive urges on scales ranging from 0 to 8. Recently, the Overvalued Ideas Scale (OVIS) has been developed to assess OVI reliably and validly^*. The purpose of this study was to determine the relationship between OVI, the degree of severity of OCD symptoms and improvement.

Method

Twenty hospitalized patients participated in this study. The diagnosis of OCD was made independently by a psychologist and a psychiatrist and was supported by data collected via the Structured Clinical Interview for the DSM-IV (SCID)²² and according to the diagnostic criteria specified in DSM-IV⁷. Prominent OCD symptoms observed included contamination fears and washing; perfectionism and ordering and arrangement; sexual and aggressive obsessions and checking as well as doubting and magical thinking. All diagnoses were confirmed separately by multimember interdisciplinary team meetings at our facility and at the hospital. Of the twenty patients, 15 were male and 5 were female. The mean age of the sample was 37.7 with ages ranging from 17 to 53 years. Average age of onset was 14.8 with onset ages ranging from 11 to 21. In the present study, 10 patients were defined as being high in Overvalued Ideas and 10 were defined as being low in Overvalued Ideas.

Measures

All patients were assessed with the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), the Beck Depression Inventory (BDI), the Beck Anxiety Inventory (BAI), and the Overvalued Ideas Scale (OVIS).

Yale-Brown Obsessive Compulsive Scale (Y-BOCS)

The Y-BOCS²³ assesses two major dimensions of OCD: obsessions and compulsions. It is a ten-item clinician administered scale that provides a score (0 to 40) of the severity of one's OCD. The total score consists of an obsessions subtotal and a compulsions subtotal. In addition, item 11 (insight) provides a crude indication of one's overvalued ideas, ranging from 0 (excellent) to 4 (absent). Reliability and validity data have been established for this widely used measure. Recent research suggests, however, that the total score is not factorily robust and that the subscales should be considered separately²⁴.

Beck Depression Inventory (BDI)

The Beck Depression Inventory is a patient administered scale which assesses the degree of depressive symptomatology experienced and endorsed. The scale consists of 21 items each containing 4 statements, one of which the patient selects to best represent him or her. The items refer to cognitions, behaviors, and somatic or physiological symptoms and reflect state, as opposed to trait-like symptoms. Reliability and validity data indicate a split-half reliability of .90 and a test-retest reliability of .75. The measure correlates well with other measures of depression. See Williams²⁵ for a further description of the scale.

Beck Anxiety Inventory

The Beck Anxiety Inventory is also a patient administered scale which assesses the degree and severity of anxiety symptomatology experienced by the patient. Twenty items list symptoms of anxiety and the patients selects the degree to which he or she is bothered or distressed by their occurrence. The items refer to the cognitive, behavioral and physiological components of anxiety and reflect state, as opposed to trait-like symptoms. Psychometric research indicates that the BAI has good internal consistency (Alpha=.92) and adequate test-retest reliability (r=.75). Convergent validity with the Hamilton Anxiety rating scale has been established (r=.51) as has discriminant validity with the Hamilton Depression Rating Scale (r=.25)²⁶.

Overvalued Ideas Scale (OVIS)

The OVIS is a 10-item clinician administered scale that can assess the extent of a patient's obsessions and associated compulsions on several different continua (see ^Appendix at the end of this article). These include how strong the obsessive belief is on a scale from 1 (belief is very weak) to 10 (belief is very strong); how reasonable the belief is (1= totally unreasonable; 10= completely reasonable); how weak and how strong the belief has fluctuated over the past week (1= belief is very weak; 10= belief is very strong); how accurate the belief is (1= totally inaccurate; 10= totally accurate); the extent to which others share the same beliefs (1= totally disagree; 10= completely agree); how the patient attributes similar or differing beliefs; how effective the compulsions are (1= totally ineffective; 10= completely effective); the extent to which their disorder has caused their obsessive belief (1=totally probable; 10= totally improbable); and their degree of resistance toward the belief (1= total resistance; 10= no resistance). The average of the 10 items provides an estimate of one's degree of OVI, where higher scores represent greater levels of OVI. Reliability and validity data indicate a total internal consistency of .95 and a test-retest reliability of .93. Convergent validity has been established with the Y-BOCS, ranging from .44 to .83, while discriminant validity has been obtained with measures of anxiety and depression using the Hamilton scales (.47 and .53, respectively). A recent modified version of the scale has numerous added anchor points and probe questions to aid the clinician in rating OVI. Preliminary results indicate that the revised OVIS has similar or better reliability and validity profiles. (Neziroglu, 1997, personal communication).

Procedure

All participants in this study entered into a one-month intensive hospitalization program for OCD, run by the Institute for Bio-Behavioral Therapy and Research, in Long Island, NY. All patients were on SSRI medications at the time of hospitalization and had been taking their respective medications in therapeutic dosages for a minimum of three months prior to their admission. No changes in medications were made throughout the course of their intensive treatment. SSRI medications used included fluoxetine, paroxetine, and fluvoxamine. In addition, all patients received intensive behavior therapy consisting of 90 minutes sessions, 6 days a week of exposure and response prevention. All patients were assessed upon admission and then again upon discharge. Upon admission, patients were divided into High and Low in Overvalued Ideation based on their pretest scores. Specifically, patients high in overvalued ideas (OVI) were defined as those who scored greater than or equal to 6 on the OVIS, whereas subjects low in overvalued ideas were defined as those who scored less than or equal to 5.5. on the OVIS.

Results

The means and standard deviations of the high and low OVI subjects are presented in Table 1. As can be seen in Table 1, those with high and low levels of OVI evidenced comparable levels of anxiety and depression at pretest, as assessed by the BAI and BDI (t[18]=.90, p<.38; t[18]=.10, p=.92, respectively). At pretest, those with high OVI scores evidenced a significantly greater degree of symptom severity as assessed on the Y-BOCS (t[18]=2.2, p<.05). Furthermore, at pretest, high OVI patients evidenced a poorer level of insight as assessed through item 11 on the Y-BOCS (t[18]=2.9, p=.01).

Among those with high levels of OVI, measures of anxiety did not decrease significantly from pretest to posttest (t[9]=2.15, p=.06). An effect size of .36 was not significant. Depression scores among those with high levels of OVI also did not decrease significantly (t[9]=1.63, p<.14) from pretest to posttest. The .45 effect size for change in depression scores was not significant. A significant decrease in their levels of overvalued ideas (t[9]=2.44, p<.05) was observed. An effect size analysis revealed a moderate effect size (d = .69), even though posttest OVI scores were still considered to be high (7.22 at pretest vs. 6.28 at posttest). However, those with high OVI did evidence a 4.8 point drop on the Y-BOCS, which was significant (t[9]=3.56, p<.01). This decrease represents a moderate effect size (d = .75), although again, posttest scores were still considered to be high (30.3 at pretest vs. 25.5 at posttest). In addition, level of insight, assessed via item 11 on the Y-BOCS, also did not decrease significantly (t[9]=1.0, p=.34). The effect size (d=.16) is considered to be small.

Among those with low levels of OVI, significant decreases were observed on the measure of anxiety (t[9]=5.29, p<.01), with a large effect size of .83. Those with low levels of OVI also evidenced significant decreases in depression at posttest (t[9]=5.37, p<.01). The effect size for this change (d = .80) is large. The level of OVI also decreased significantly from pretest to posttest (t[9]=5.04, p<.01) and evidenced a large effect size (d= .88). Those with low levels of OVI evidenced an 8-point drop on the Y-BOCS, which was significant and reduced their scores from severe at pretest to moderate at posttest (t[9]=7.37, p<.01). The effect size for this measure was large (d= 1.40). A decrease in level of insight from 1.3 at pretest to 1.2 at posttest was not significant (t[9]=1.0, p=.34).

A 2 (high vs. low OVI) x 2 (pre-post) ANOVA examining anxiety scores did not yield a significant between or within subjects main effect (F[1,18] = 1.84, p= .19; d=.09; F[1,18] = .17, p= .68; d<.01, respectively) and the interaction of anxiety scores and level of OVI was also not significant (F[1,18] = .65, p = .43; d= .03). While patients high in OVI evidenced a 2 points decrease in Beck anxiety scores, patients low in OVI evidenced a 6 point decrease in Beck anxiety scores. These decreases were not significant, however. A 2 (high vs. low OVI) x 2 (pre-post) ANOVA examining depression scores indicated that those with low OVI were significantly less depressed at posttest (F[1,18] = 31.41, p < .01). In addition, the interaction of OVI level and Beck depression scores was significant (F[1,18] = 5.52, p = .03), indicating that patients with lower levels of OVI experienced greater decreases in depression following the treatment.

Since high and low OVI patients differed significantly at pretest on OVIS, Y- BOCS and Y-BOCS # 11 scores, these scores were used as co-variants. Separate ANCOVAS indicated that low OVI patients evidenced significant decreases in their levels of OVI compared to high OVI patients (F[1,17] = 16.14, p < .01; d=.48). In addition, those with low OVI also evidenced a significantly greater decrease in symptom severity as assessed via the Y-BOCS over and above the decrease seen in those with high levels of OVI (F[1,17] = 18.12,p < .01; d= .51). Level of insight at posttest was significantly better for those with low levels of OVI compared to those with high levels of OVI (F[1,17] = 74.83, p <.01). The posttest differences are presented in Figure 1.

With regard to the relationship between OVI and symptom severity as assessed via the Y-BOCS, partial correlations between OVI and the Y-BOCS, controlling for the level or severity of overvalued ideas, were not significant either at pretest or at posttest (r[17]=.18, p=.47; r[17]=.26, p=.28, respectively). These results indicate the overvalued ideas do not necessarily correlate with symptom severity.

Discussion

This study sought to determine the relationship between OVI, degree of OCD symptom severity and improvement following a one month intensive treatment program using combined behavior and pharmacological therapy modalities. The results indicate that patients with high levels of OVI carry with them prognostic variables, in addition to the high level of OVI, that interfere with treatment from the outset. Interestingly, OVI and symptom severity, as assessed through the Y-BOCS, do not necessarily correlate; those with low levels of OVI also evidenced fairly severe Y-BOCS scores.

Among those with high levels of OVI, the intensive treatment appeared to impact mainly on the overvalued ideas themselves and only somewhat on the OCD symptom severity. Treatment, however, did not impact levels of anxiety or depression. Results from the present study suggest that the level of OVI negatively impacted treatment. At the end of one month, patient's symptom severity decreased but they were still clinically in the severe range. Perhaps a longer treatment phase is necessary. Relapse is a likely factor.

Those with low levels of OVI, on the other hand, evidenced significant changes on all measures except for level of insight that decreased non- significantly from 1.3 at pretest to 1.2 at posttest. The insight item of the Y-BOCS ranges from 0 (excellent) to 4 (absent) and scores of 0 or 1 do not reflect a loss of insight. They also evidenced significant decreases in anxiety and depression levels, they exhibited a greater decrease in OCD symptom severity and levels of OVI.

In comparing the high and low OVI patients at posttest, while covarying pretest differences in OVI, Y-BOCS, and Y-BOCS#11 scores, results indicated that those with low levels of OVI improved on all measures except for anxiety. It should be noted, however, that those with low levels of OVI evidenced a 6-point drop in anxiety scores at posttest, compared to a 2-point drop among those with high levels of OVI. These changes, while not statistically different, may have been phenomenologically significant for the patients themselves.

It should perhaps be recommended that high OVI candidates for intensive behavior and pharmacological therapy receive such treatment for longer durations. Patients high in OVI should perhaps be `pre-treated' to reduce their level of OVI first, allowing for a greater subsequent impact of combined behavioral and pharmacological therapies. Although hospital stays are becoming shorter and shorter, contingencies could be set to continue treating such patients intensively on an outpatient basis for several months following discharge as well. In addition, other specifically proven modalities such as the recently developed cognitive therapy that targets specific cognitive errors among those with OCD²⁷ could perhaps be included prior to and throughout the course of treatment and follow-up in attempts to dislodge the rigid belief structures and behavioral avoidance tendencies of those with high levels of OVI.

Correspondence

Fugen A. Neziroglu

The Institute for Bio-Behavioral Therapy and Research,

Suite 102, Great Neck, NY, 11021, USA.

APPENDIX

OVERVALUED IDEA SCALE (Copyright 1996)

Fugen A. Neziroglu, Jose A. Yaryura -Tobias,

Dean R. McKay, Kevin Stevens, John Todaro

Institute for Bio-Behavioral Therapy & Research

935 Northern Blvd.

Great Neck, NY 11021

[phone]

Name:

Date:

Complete the following questions about obsessions and/ or compulsions which the patient reports as being applicable on the average in the PAST WEEK INCLUDING TODAY.

List the main belief which the patient has had in the last week. It should be the one that is associated with the greatest distress or impairment in social and occupational functioning to the patient as assessed by the rater (e.g., I will get AIDS if I do not wash properly after visiting the hospital, my house may burn down if I do not check the stove before leaving the house, I may lose important information if I throw out items that I collect, I am unattractive, my nose is misshapen, my complexion is full of pimples, etc.). The ratings should reflect the patient's beliefs (e.g., how reasonable does the patient perceive the belief, how effective does the patient believe the compulsions are in preventing the feared consequences, etc.). Only list a belief related to obsessive-compulsive disorder. Rate all items according to your evaluation of the patient's belief. You may use the three questions provided below each category to assess various aspects of the belief, e.g. strength, reasonableness.

Describe the main belief below:

As you rate the patient on each of the items incorporate the patient’s specific belief, e.g. How strong is your belief that you will get AIDS if you visit the hospital?

1) STRENGTH OF BELIEF

In the past week, including today;

How strongly do you believe that ___ is true?

How certain/convinced are you this belief is true?

Can your belief be ‘shaken’ if it is challenged by you or someone else?

(Very weak to very strong refer to the possibility of the belief being true, i.e. very weak-minimally possible; very strong-extremely possible.)

Rating Item 1:_______

2) REASONABLENESS OF BELIEF

In the past week, including today;

How reasonable is your belief?

Is your belief justified or rational?

Is the belief logical or seem reasonable?

Rating Item 2:________

Overvalued Ideas Scale 24

3) LOWEST STRENGTH OF BELIEF IN PAST WEEK

In the last week, what would you say was the lowest rating of strength for your belief?

How weak did your belief become in the last weak?

Were there times in the past week that you doubted your belief, even for a fleeting moment, whether____ was true? If so, tell me more about it?

Rating Item 3:_________

4) HIGHEST STRENGTH OF BELIEF IN PAST WEEK

In the last week, what was your highest rating of strength for your belief?

How strong did your belief become in the last week?

How certain/convinced were you about your belief in the past week?

Rating Item 4:_________

53) ACCURACY OF BELIEF

In the past week, including today;

How accurate is your belief?

How correct is your belief?

To what degree is your belief erroneous?

Rating Item 5:_________

6) EXTENT OF ADHERENCE BY OTHERS

How likely is it that others in the general population (in the community, state, country, etc.) have the same beliefs?

How strongly do these others agree with your belief?

To what extent do these others share your belief?

Rating Item 6:___________

7) ATTRIBUTION OF DIFFERING VIEWS BY OTHERS

Do others share the same belief as you? Yes____ NO____

If the patient answers Yes go to 7a, if the patient answers NO go to 7b.

7a) VIEWS OTHERS AS POSSESSING SAME BELIEF

Since you think others agree with your belief, do you think they are as knowledgeable as you about this belief?

To what extent do you believe others are as knowledgeable about the belief as you are?

Do you believe others have as much information as you about this belief?

Rating Item 7a:_________

7b) VIEWS OTHERS AS HOLDING DIFFERING BELIEF

Since you think others disagree with you, do you think they are less knowledgeable than you about this belief?

To what extent do you believe others are less knowledgeable about the belief than you are?

Do you believe others have less information than you about this belief?

Rating Item 7b:_________

8) EFFECTIVENESS OF COMPULSIONS

In the past week, including today;

How effective are the compulsions/ritualistic behaviors in preventing negative consequences other than anxiety?

Are your compulsions of any value in stopping the feared outcome?

Is it possible that your compulsions may not help prevent the negative outcomes?

Rating Item 8:_________

9) INSIGHT

To what extent do you think that your disorder has caused you to have this belief?

How probable is it that your beliefs are due to psychological or psychiatric reasons?

Do you think that your belief is due to a disorder?

Rating Item 9:________

10) STRENGTH OF RESISTANCE

How much energy do you put into rejecting your belief?

How strongly do you try to change your belief?

Do you attempt to resist your belief?

Rating Item 10:________

11) DURATION OF BELIEF

a) During the time that you have had this belief did it ever fluctuate?

If so, within what period of time?

Check one of the following:

___ ____ _____ ____

Day Week Month Year

b) In retrospect, how long have you held this particular belief?

Check one of the following:

___ ____ _____ ____

Day Week Month Year

• 1. Reiger DA, Boyd HH, Burke JD et al. One month prevalence of mental disorders in the United States. Arch Gen Psychiatry 1988;45:977-8.
• 2. Kringlen E. Obsessional neurotics. Br J Psychiatry 1965;111:709-72.
• 3.Bertschy G, Ahyi RG. Obsessive-compulsive disorder in Benin: Five case reports. Psychopathology 1991;24:398-401.
• 4. Haffner RJ, Miller RJ. Obsessive-compulsive disorder: An exploration of some unresolved clinical issues. Australian and New Zealand J Psychiatry 1990;24:480-5.
• 5. LeGrand du Saulle H. La folie du doute avec delire du toucher. Paris, France: Delahaye; 1875.
• 6. Westphal C. Über Zwangsvorstellungen. Arch Psychiatry and Nervous Disease 1878;8:734-50.
• 7. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4^th ed. Washington (DC): Author.
• 8. Wernicke C. Grundrisse der Psychiatrie. (Foundations of Psychiatry). Chap. 22. Leipzig: Verlag; 1906.
• 9. Jaspers K. Psicopathologia General (General Psychopathology). Translated by Saubidet RO. Buenos Aires, Argentina: Beta Publishers; 1913.
• 10. Kozak MJ, Foa EB. Obsessions, overvalued ideas, and delusions in obsessive compulsive disorder. Behaviour Research and Therapy 1994;32:343-53.
• 11. Fishbain DA, Trescott J, Cutler B, Abdel ME et al. Do some chronic pain patients with atypical facial pain overvalue and obsess about their pain? Psychosomatics 1993;34:355-9.
• 12. Philips KA, McElroy SL. Insight, overvalued ideas and delusional thinking in body dysmorphic disorder: Theoretical and treatment implications. J Nervous and Mental Disease 1993;181:699-702.
• 13. Neziroglu FA, Yaryura-Tobias JA. Exposure, response prevention, and cognitive therapy in the treatment of body dysmorphic disorder. Behavior Therapy 1993;24:431-8.
• 14. Bruce BK, Stevens VM. AIDS-related obsessive-compulsive disorder: A treatment dilemma. J Anxiety Disorders 1992;6:79-88.
• 15. Foa EB. Failures in Treating Obsessive-Compulsives. Behavior Research and Therapy 1979;17:169-176.
• 16. Lelliot PT, Noshirvani HF, Basoglu M. Obsessive-compulsive beliefs and treatment outcome. Psychological Medicine 1988;18:697-702.
• 17. Abel JL. Exposure and response prevention and serotonergic antidepressants in the treatment of obsessive-compulsive disorder: A review and implications for interdisciplinary treatment. Behavior Research and Therapy 1993;31:463-78.
• 18. Yaryura-Tobias JA, Stevens KP, Neziroglu FA, Grunes M. Obsessive-compulsive disorder and schizophrenia: A phenomenological perspective of shared pathology. CNS Spectrums 1997;4:21-5.
• 19. Basoglu M, Lax T, Kasvikis Y, Marks IM. Predictors of improvement in obsessive-compulsive disorder. J Anxiety Disorders1988;2:299-317.
• 20. Foa E, Kozak MJ. DSM-IV field trial: Obsessive-Compulsive Disorder. Behavior Therapy and Research 1994;32:169-76.
• 21. Foa EB, Kozak MJ, Goodman WK, Hollander E, Jenike MA, Rasmussen SA. DSM-IV Field Trial: Obsessive-compulsive disorder. Am J Psychiatry 1995;152:90-6.
• 22. Spitzer RL, Williams JBW, Gibbon M, First M. Manual for the Structured Clinical Interview for DSM-III-R with Psychotic Screen. Washington (DC): American Psychiatric Press; 1991.
• 23. Goodman WK, Price LH, Rasmussen SA, Mazure C, Fleischmen RL, Hill CL, Heiniger GR, Charney DS. The Yale Brown Obsessive Compulsive Scale: I. Development, use and reliability. Arch Gen Psychiatry 1989;46:1006-11.
• 24. McKay D, Danyko SJ, Neziroglu FA, Yaryura-Tobias JA. Factor structure of the Yale-Brown Obsessive-Compulsive Scale: A two dimensional measure. Behavior Research and therapy 1995;33:865-9.
• 25. Williams JMG. The Psychological Treatment of Depression. New York: Free Press; 1984.
• 26. Beck AT, Epstein N, Brwon G, Steer RA. An inventory for measuring clinical anxiety: Psychometric properties. J Consulting and Clinical Psychology 1988;56:893-7.
• 27. Obsessive Compulsive Cognitions Working Group. Cognitive assessment of obsessive-compulsive disorder. Behavior Research and therapy 1997;35:667-91.

Appendix

¹

. The Institute for Bio-Behavioral Therapy and Research - Department of BiopsychoSocial Research, Great Neck (NY), EUA.

*

Neziroglu FA, McKay D, Yaryura-Tobias JA, Stevens KP, Todaro J. The Overvalued Ideas Scale: Development, Reliability, and Validity in Obsessive Compulsive Disorder. Behavior Research and Therapy 1999. (Under Review)

Publication Dates

• Publication in this collection
  12 June 2000
• Date of issue
  Dec 1999