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An effective primary treatment for obsessive-compulsive disorder (OCD) in children and adolescents as well as adults is exposure and response prevention (ERP), a form of intervention in the context of cognitive-behavioral therapy. Despite strong evidence supporting the efficacy and effectiveness of ERP from studies in research and real-world settings, its clinical use remains limited. This underuse is often attributed to access barriers such as the scarcity of properly trained therapists, geographical constraints, and costs. Some of these barriers may be addressed with virtual behavioral health, providing ERP for OCD through video teletherapy and supplemented by app-based therapeutic tools and messaging support between sessions. Studies of teletherapy ERP in adults with OCD have shown benefits in research and real-world settings in both small and large samples. However, studies of teletherapy ERP in children and adolescents thus far have been in small samples and limited to research rather than real-world settings. This study reports on the real-world effectiveness of teletherapy ERP for OCD in the largest sample (N=2173) of child and adolescent patients to date. Children and adolescents with OCD were treated with live, face-to-face video teletherapy sessions, with parent or caregiver involvement, using ERP. Assessments were conducted at baseline, after 7-11 weeks, and after 13-17 weeks. Additionally, longitudinal assessments of OCD symptoms were performed at weeks 18-30, 31-42, and 43-54. We analyzed longitudinal outcomes of OCD symptoms, depression, anxiety, and stress using linear mixed models. Treatment resulted in a median 38.46% (IQR 12.50%-64.00%) decrease in OCD symptoms at 13-17 weeks, and 53.4% of youth met full response criteria at this point. Improvements were observed in all categories of starting symptom severity: mild (median 40.3%, IQR 8.5%-79.8%), moderate (median 38.4%, IQR 13.3%-63.6%), and severe (median 34.1%, IQR 6.6%-58.5%). In addition, there were significant reductions in the severity of depression, anxiety, and stress symptoms. The median amount of therapist involvement was 13 (IQR 10.0-16.0) appointments and 11.5 (IQR 9.0-15.0) hours. Further, symptom improvements were maintained or improved upon in the longitudinal assessment periods of weeks 18-30, 31-42, and 43-54. These results show that remote ERP treatment, assisted by technology, can effectively improve both core OCD and related depression, anxiety, and stress symptoms in children and adolescents with OCD in a real-world setting. Notable outcomes were achieved in a relatively small amount of therapist time, demonstrating its efficiency. Demonstrating the usefulness of a delivery format that overcomes several traditional barriers to treatment, these findings have implications for widespread dissemination of accessible, evidence-based care for children and adolescents with OCD.

Exposure and response prevention, a type of cognitive-behavioral therapy, is an effective first-line treatment for obsessive-compulsive disorder (OCD). Despite extensive evidence of the efficacy of exposure and response prevention (ERP) from clinical studies and in real-world samples, it is still underused as a treatment. This is likely due to the limits to access to care that include the availability of adequately trained therapists, as well as geographical location, time, and cost barriers. To address these, NOCD created a digital behavioral health treatment for OCD using ERP delivered via video teletherapy and with technology-assisted elements including app-based therapy tools and between-session therapist messaging. We examined treatment outcomes in a large naturalistic sample of 3552 adults with a primary OCD diagnosis who received NOCD treatment. The treatment model consisted of twice-weekly, live, face-to-face video teletherapy ERP for 3 weeks, followed by 6 weeks of once-weekly brief video teletherapy check-ins for 30 minutes. Assessments were conducted at baseline, at midpoint after completion of 3 weeks of twice-weekly sessions, and at the end of 6 weeks of brief check-ins (endpoint). Longitudinal assessments were also obtained at 3, 6, 9, and 12 months after endpoint. Treatment resulted in clinically and statistically significant improvements, with a 43.4% mean reduction in obsessive-compulsive symptoms (g=1.0; 95% CI 0.93 to 1.03) and a 62.9% response rate. Treatment also resulted in a 44.2% mean reduction in depression, a 47.8% mean reduction in anxiety, and a 37.3% mean reduction in stress symptoms. Quality of life improved by a mean of 22.7%. Reduction in OCD symptoms and response rates were similar for those with mild, moderate, or severe symptoms. The mean duration of treatment was 11.5 (SD 4.0) weeks, and the mean total therapist time was 10.6 (SD 1.1) hours. Improvements were maintained at 3, 6, 9, and 12 months. In this sample, representing the largest reported treated cohort of patients with OCD to date, video teletherapy treatment demonstrated effectiveness in reducing obsessive-compulsive and comorbid symptoms and improved quality of life. Further, it achieved meaningful results in less than half the total therapist time compared with standard once-weekly outpatient treatment, an efficiency that represents substantial monetary and time savings. The effect size was large and similar to studies of in-person ERP. This technology-assisted remote treatment is readily accessible for patients, offering an advancement in the field in the dissemination of effective evidence-based care for OCD.

Although exposure therapy is effective in reducing eating-related fears and avoidance in individuals with eating disorders (EDs), there has been little study of this treatment in inpatient settings. To address this gap, we conducted a case series to evaluate the effects of a food-based exposure therapy intervention on eating-related fears and avoidant behaviors among adults being treated for an ED in an inpatient hospital setting. Patients (N = 106) were provided psychoeducation on the treatment approach, aided in the development of an exposure hierarchy containing fear-evoking stimuli related to eating (e.g., feared foods), and guided in completing exposure exercises and gradually progressing through the hierarchy. Results showed that patients experienced significant reductions in eating-related fears and avoidant behaviors from pretreatment to posttreatment. Acceptability of the intervention was reasonably well-established by (a) acceptable rates of treatment participation and completion, (b) favorable ratings of the intervention provided in a posttreatment satisfaction survey, and (c) the absence of any exacerbations in the frequency of compensatory weight control behaviors (e.g., self-induced vomiting) over the course of treatment. Clinical implications of these findings are discussed in the light of clinicians’ concerns about and underutilization of food-based exposure therapy for EDs, particularly in inpatient settings.

Network analysis is an emerging approach in the study of psychopathology, yet few applications have been seen in eating disorders (EDs). Furthermore, little research exists regarding changes in network strength after interventions. Therefore the present study examined the network structures of ED and co-occurring depression and anxiety symptoms before and after treatment for EDs. Participants from residential or partial hospital ED treatment programs (N = 446) completed assessments upon admission and discharge. Networks were estimated using regularized Graphical Gaussian Models using 38 items from the Eating Disorders Examination-Questionnaire, Quick Inventory of Depressive Symptomatology, and State-Trait Anxiety Inventory. ED symptoms with high centrality indices included a desire to lose weight, guilt about eating, shape overvaluation, and wanting an empty stomach, while restlessness, self-esteem, lack of energy, and feeling overwhelmed bridged ED to depression and anxiety symptoms. Comparisons between admission and discharge networks indicated the global network strength did not change significantly, though symptom severity decreased. Participants with denser networks at admission evidenced less change in ED symptomatology during treatment. Findings suggest that symptoms related to shape and weight concerns and guilt are central ED symptoms, while physical symptoms, self-esteem, and feeling overwhelmed are links that may underlie comorbidities in EDs. Results provided some support for the validity of network approaches, in that admission networks conveyed prognostic information. However, the lack of correspondence between symptom reduction and change in network strength indicates that future research is needed to examine network dynamics in the context of intervention and relapse prevention.

BackgroundNegative illness representations such as self-blame impede treatment-seeking behavior and therapy motivation in individuals with eating disorders (EDs). However, only one study so far has investigated how different explanatory models influence these beliefs in EDs. We aimed to expand these findings by introducing an explanatory model based on network theory (NT).MethodsWe presented three explanatory models to a diverse web-recruited sample (n = 290, 141 females, 149 males) with clinically elevated ED symptomatology. Participants either watched a video with a biological-genetic (BG), cognitive-behavioral (CB) or an NT explanatory model and were asked about illness representations before and after watching the video.ResultsThe BG group showed significantly greater reductions in self-blame but a significant decrease in personal control and less optimistic expectation regarding timeline compared to the CB and NT groups. There were no group differences regarding the perception of the clinician, comprehensibility of the explanatory model and credibility of a CBT intervention.ConclusionsGiven the increasing popularity of biological-genetic explanatory models of EDs, it is important to note the disadvantages we found to be associated with these models. Our findings indicate that explanatory models emphasizing cognitive-behavioral (CB) principles and/or network theoretical (NT) underpinnings of EDs may serve to promote optimism and greater perceptions of personal agency in affected populations.This trial's registration number is 316.

This study examines the impact of three different etiological explanations on self-stigmatizing attitudes among individuals with clinical symptom levels of either major depressive disorder (MDD; n = 144) or social anxiety disorder (SAD; n = 175). Participants were randomly assigned to view an audiovisual presentation describing their symptoss as being caused by biological (BIO) or cognitive-behavioral (CB) factors, or their combination (BIO+CB). Self-blame and perceived helplessness were significantly greater in the CB condition compared to the BIO condition. There was no significant difference in prognostic pessimism, perceived dangerousness, and unpredictability between the CB and BIO conditions. All self-stigmatizing attitudes were worse in the BIO+CB condition compared to the BIO condition. The MDD group endorsed significantly higher levels of self-stigmatizing attitudes compared to the SAD group. The present findings suggest that cognitive-behavioral etiological explanations may increase self-stigma compared to biological-only explanations. Combined biological and cognitive-behavioral explanations appear to have a particularly negative impact on self-stigmatizing attitudes among people with clinical levels of MDD or SAD symptoms. Individuals with symptoms of MDD generally endorse more self-stigmatizing attitudes compared to those with symptoms of SAD, even when controlling for general hopelessness. The clinical implications of these findings are discussed.

Given the central role of government workers in maintaining order, the First Amendment rights of public employees have been particularly susceptible to restriction. For example, in 1940, Congress enacted the Hatch Act, which declared unlawful certain political activities of federal employees. Specifically, section nine of the Act prohibited officers and employees in the executive branch from taking any active part in political management or in political campaigns. The idea that a politically active government staff threatens effective administration has filtered down to the state and local level since the passage of the Hatch Act. The most disturbing element of modern public confidence laws is that courts have allowed them to extend so far as to prevent even spouses and family members of state and local employees from participating in politics. In light of the importance of the First Amendment to citizens of the United States, it is unacceptable that many courts have rendered the families of public employees helpless to challenge such blatant violations of their constitutional right to free speech.

Owing to concerns about the safety, tolerability, and ethicality of exposure therapy, many clinicians deliver the treatment in an overly cautious manner, thereby limiting its effectiveness. Although didactic training in exposure reduces clinicians’ concerns somewhat, improved training strategies are needed to minimize these concerns and improve exposure delivery. The present study compared the effectiveness of a standard (i.e., didactic) exposure therapy training model to an “enhanced” training paradigm encompassing strategies derived from social-cognitive theory on attitude change. Clinicians (N = 49) were assigned to one of the two exposure training approaches. Relative to standard training, clinicians who received enhanced training evidenced significantly less concerns about exposure, superior delivery of the treatment, and greater confidence in its use. Reduction in concerns from pre- to post-workshop fully mediated the effects of training condition on clinicians’ exposure delivery. These findings underscore the necessity of addressing clinician concerns about exposure therapy in training contexts.

Despite its effectiveness in treating anxiety disorders, exposure therapy is underutilized and frequently implemented in suboptimal fashion. Previous research has shown that holding negative beliefs about exposure was related to its underutilization among therapists. However, negative beliefs about exposure are not unique to therapists who do not use the treatment. It could be that negative beliefs about exposure are held even by therapists who continue to use the treatment, and these beliefs are responsible for therapists' suboptimal delivery of the treatment. The present study examined the effect of beliefs about exposure on characteristics of treatment delivery. Participants (n = 53) were randomly assigned to receive either negative or positive information about exposure therapy before conducting an exposure session with a presumed obsessive-compulsive client. Results indicated that participants with negative beliefs about exposure implemented the treatment in a more cautious manner (e.g. choosing easier exposure tasks) as compared to participants with positive beliefs about exposure who pursued a more ambitious delivery of the treatment (e.g. creating a more difficult exposure hierarchy, encouraging clients' use of oppositional actions).

A conspicuous roadblock to studying marine bacteria for fundamental research and biotechnology is a lack of modular synthetic biology tools for their genetic manipulation. Here, we applied, and generated new parts for, a modular plasmid toolkit to study marine bacteria in the context of symbioses and host-microbe interactions. To demonstrate the utility of this plasmid system, we genetically manipulated the marine bacterium Pseudoalteromonas luteoviolacea , which stimulates the metamorphosis of the model tubeworm, Hydroides elegans . Using these tools, we quantified constitutive and native promoter expression, developed reporter strains that enable the imaging of host-bacteria interactions, and used CRISPR interference (CRISPRi) to knock down a secondary metabolite and a host-associated gene. We demonstrate the broader utility of this modular system for testing the genetic tractability of marine bacteria that are known to be associated with diverse host-microbe symbioses. These efforts resulted in the successful conjugation of 12 marine strains from the Alphaproteobacteria and Gammaproteobacteria classes. Altogether, the present study demonstrates how synthetic biology strategies enable the investigation of marine microbes and marine host-microbe symbioses with potential implications for environmental restoration and biotechnology. Marine Proteobacteria are attractive targets for genetic engineering due to their ability to produce a diversity of bioactive metabolites and their involvement in host-microbe symbioses. Modular cloning toolkits have become a standard for engineering model microbes, such as Escherichia coli , because they enable innumerable mix-and-match DNA assembly and engineering options. However, such modular tools have not yet been applied to most marine bacterial species. In this work, we adapt a modular plasmid toolkit for use in a set of 12 marine bacteria from the Gammaproteobacteria and Alphaproteobacteria classes. We demonstrate the utility of this genetic toolkit by engineering a marine Pseudoalteromonas bacterium to study their association with its host animal Hydroides elegans . This work provides a proof of concept that modular genetic tools can be applied to diverse marine bacteria to address basic science questions and for biotechnology innovations.