Obsessions and Time of Day: A Self-Monitoring Study in Individuals With Obsessive-Compulsive Disorder.

Deepening our understanding of the basic mechanisms underlying obsessive-compulsive disorder (OCD) often leads to advances in clinical practice. And, as noted by Kazdin (2008), clinical experiences are an important resource for identifying novel targets for empirical study. One potential target for furthering our understanding of OCD is to investigate clinical reports of within-day symptom fluctuations. Self-monitoring data from 17 adults with OCD were used to test for a diurnal pattern in obsessions. Results from generalized estimating equations revealed that obsessions were most common during midday and that the midday exacerbation was briefer in males. In combination with prior findings of similar diurnal patterns for other anxious symptoms (e.g., panic), these findings suggest that daily social rhythms and/or circadian influences may influence levels of obsessions. Furthermore, treatment may be improved by attending to these heightened symptom periods and integrating this information into therapy (e.g., when developing the exposure hierarchy).Keywords: obsessive-compulsive; anxiety; circadian; self-monitoring; generalized estimating equationsDeepening our understanding of the basic mechanisms underlying obsessive-compulsive disorder (OCD) often leads to advances in clinical practice. And, as noted by Kazdin (2008), clinical experiences are an important resource for identifying novel targets for empirical study. Individuals with OCD frequently report experiencing symptoms throughout the day. Some individuals report experiencing their symptoms as occurring randomly or when triggered by the environment, whereas others report feeling as though their symptoms are a constant burden throughout their waking hours. Indeed, the perceived uncontrollable or inescapable nature of OCD symptoms can be a contributor to the distress and impairment associated with the disorder. Clinicians working with individuals with OCD often begin by helping their clients identify antecedents to their symptoms and better understand the maintenance of their OCD symptoms. In their efforts to do this, several clinicians have noted that there may be patterns to the fluctuations related to the time of day. Indeed, Rachman (2002) described a patient whose symptoms were most disruptive at night, spending hours engaging in compulsive rituals after his family members went to bed. Similarly, in our clinic, patients have reported increased symptom-related distress late at night (e.g., Coles & Sharkey, 2011). According to these reports, increases in compulsions at night were related to greater difficulty dismissing intrusive thoughts and obsessions that the actions must be performed "perfectly." However, case studies and anecdotal evidence cannot adequately specify whether these patterns are unique to certain individuals or whether they reflect a more universal pattern across individuals with OCD.Diurnal patterns across individuals have been identified for other psychopathological constructs including depressive rumination and panic symptoms. Interestingly, different patterns were identified for each construct: Depressive rumination was found to have the lowest levels in the afternoon and increases in the morning and evening (Moberly & Watkins, 2008; Takano & Tanno, 2011), whereas panic symptoms were found to have their highest levels in the afternoon with decreases in the morning and evening (Cameron, Lee, Kotun, & McPhee, 1986; Kenardy, Fried, Kraemer, & Taylor, 1992). Information from these studies could be applied to clinical practice to further patient's understanding of symptoms, inform more targeted and effective treatment (e.g., timing of medication doses or therapy sessions; Portaluppi & Smolensky, 2001), and generate hypotheses regarding the mechanisms of patients' experiences (Myin-Germeys et al., 2009). For example, symptom fluctuations within a day may be related to social rhythms such as work schedules, time spent with others, timing of meals, or exercise. …