Obsessive-Compulsive Disorder

General psychological symptoms were assessed using the Symptom Checklist-90-Revised [21 ] at baseline, and its abbreviated version, the Brief Symptom Inventory (BSI) [22 ], at follow-up. Both versions are based on identical items and have been shown to present fairly equivalent psychometric properties [23 (link), 24 (link)]. Hence, we focused our analyses on the BSI. The BSI is a widely used 53-item measure of subjective psychological distress experienced in the preceding seven days. All responses are scored on a 5-point scale from 0 (“not at all”) to 4 (“extremely”). The BSI’s nine subscales cover symptoms of clinically relevant psychological syndromes: somatization, obsessive-compulsive disorder, interpersonal sensitivity, depression, anxiety, phobic anxiety, paranoid ideation, and psychoticism. The Global Severity Index (GSI) is a measure of overall psychological distress and is calculated by summing up all nine subscales. Urbán and colleagues [24 (link)] proposed a bifactor model that supports reporting the nine subscales in addition to the rather sound GSI as outcome measures. In this study, Cronbach’s alpha of the GSI was .97 and .96 at baseline and follow-up, respectively.

42 Dutch patients were clinically assessed using a standard psychiatric interview by five psychiatrists experienced in obsessive-compulsive spectrum disorders. The general medical history as well as the psychiatric history was collected for all patients. Personality pathology was evaluated using the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II) [6] . The following questionnaires were completed:
The Hamilton Depression Rating Scale (HAM-D) [7] (link), a 17-item scale determining a patient’s level of depression.
The 14-item Hamilton Anxiety Rating Scale (HAM-A) [8] (link), which measures the severity of anxiety symptoms.
The Symptom Checklist (SCL-90) [9] (link), which is a widely used screening instrument for mental and physical dysfunctioning. The 90 items comprise eight subscales: Agoraphobia, Anxiety, Depression, Somatic complaints, Insufficiency in thinking and acting, Suspicion and interpersonal sensitivity, Hostility and Sleep problems. The total score is seen as a general index for psychoneuroticism.
To measure the severity of the misophonia symptoms, we developed an adapted version of the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) [10] (link), [11] (link), which we have named the Amsterdam Misophonia Scale (A-MISO-S). Similar adaptations of the Y-BOCS have appeared to be reliable and valid measures of symptom severity in other obsessive-compulsive and impulse control disorders, such as pathological gambling (PG-YBOCS) [12] and body dysmorphic disorder (BDD-YBOCS) [13] .
On a 6-item scale (range 0–24) patients were asked about the (1) time they spent on misophonia; (2) interference with social functioning; (3) level of anger; (4) resistance against the impulse; (5) control they had over their thoughts and anger; and (6) time they spent avoiding misophonic situations. Scores from 0–4 are considered subclinical misophonic symptoms, 5–9 mild, 10–14 moderate, 15–19 severe, 20–24 extreme.
To rule out any potential hearing problems we randomly selected five patients to perform a standard hearing test, including pure tone, speech audiometry and loudness discomfort levels, which are commonly performed to objectify hearing loss or distortion [14] , [15] . One patient’s test showed unexplained conductive hearing loss. In the other four patients no significant audiological distortion was found and further testing was therefore omitted.
The medical ethics testing committee of the Academic Medical Center did not require approval because this study was anecdotal and observational. All patients gave written informed consent for publication.

We aim to establish a cohort of 800 patients referred to the Danish treatment packages for unipolar first-episode, non-psychotic depression during 2021–2025. We recruit patients from all six clinics in the region. Each clinic receives approximately 100–250 treatment referrals yearly, and approximately 1100 patients are referred yearly. Approximately 80% of referrals are sent directly to the clinics. Patients are recruited during evaluation at the central diagnostic and referral centre or the first consultation in the clinics. Approximately 88% of referrals result in treatment package initiation.
During 2019–2020, 37% of patients were on an antidepressant (usually the selective serotonin reuptake inhibitor (SSRI) Sertraline from their GP) when starting the treatment package, and 54% of patients ended the treatment package on an antidepressant medication. 13% of patients were transferred to a treatment package for a different primary diagnosis group, e.g., generalised, social anxiety, post-traumatic stress disorder, emotionally unstable personality, avoidant personality disorder, eating disorder or obsessive–compulsive disorder. 20% dropped out of treatment. 5% of patients were hospitalised during their treatment package; hospitalization does not preclude the continuation of the treatment package.
The treatment package is a program with manualised psychotherapy in groups of eight patients as the core treatment module together with psychoeducation for the patient and relative (Sup. Table 1). In brief, a treatment package consists of 15–18 h: 2–3 h of initial workup followed by 6 h of individual therapy or 12 sessions of 2 h group therapy (8 patients per group); 1–2 h of engagement and psychoeducation of relatives; 1–5 h of medication clinic; and 2 h of relapse prevention. The program is designed around group-based CBT, but clinics also offer alternatives to CBT, e.g., psychodynamic and schema therapy, and groups for specific demographics, e.g., men or adolescents, and individual therapy. Medication is available as needed.
The research and assessment at baseline for recruited participants is conducted at the Neurobiology Research Unit (NRU) at the Copenhagen University Hospital Rigshospitalet and followed by clinicians from the Mental Health Centre Copenhagen who are not involved in the patient's treatment.

Given the prominence of Google as a search engine (eg, Google accounts for roughly 88% of the search engine market in the United States [23 ]), these analyses leveraged Google Trends, which allows for public access to search term volume for a given time and location. Several studies have leveraged Google Trends data to examine how mental health information is sought out [22 (link),24 (link),25 (link)]. As can be found in the documentation for Google Trends, the raw counts for a given search term are normalized by location and time of search and then scaled to a number from 0 to 100 representing the proportion of searches on all topics that the given term constitutes. Such normalization allows for easier comparison across geographic regions, where population may play a significant role in relative search term popularity. This analysis downloaded data from Google Trends using the gtrendsR package in R (version 1.4.8; R Foundation for Statistical Computing) [26 ]. To obtain data with the most granularity, hourly trend data were queried. The areas of interest were the 50 states constituting the United States; thus, search terms were normalized across states. As Google Trends only stores hourly data for up to 7 days, hourly data were programmatically pulled each Monday from March 23, 2020, to March 29, 2021. This period of 372 days spans the early days of the pandemic to the widespread availability of the COVID-19 vaccine in the United States. During this time frame, 39 states implemented statewide mask mandates, most of which went into effect before or during the summer of 2020. Thus, the given time frame allowed for careful introspection into the short- and long-term effects of mask mandate implementation on mental health search term activity.
The following 19 mental health search terms were queried from Google Trends, as described previously: “anxiety,” “depression,” “ocd” (obsessive-compulsive disorder), “hopeless,” “angry,” “afraid,” “apathy,” “worthless,” “worried,” “restless,” “irritable,” “tense,” “scattered,” “tired,” “avoiding,” “procrastinate,” “insomnia,” “suicidal,” and “suicide.” Aligning with previous work by the authors [10 (link),22 (link)], these terms were validated from previous research on using Google Trends to assess mental health [27 (link)], as well as from previous research assessing rapid affective symptom changes as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [28 ,29 (link)]. In addition to these terms, physical health search terms, both without known associations to COVID-19 (“abrasion,” “allergic,” “angina,” “apnea,” “bleeding,” “blister,” “bruising,” “conjunctivitis,” “constipation,” “discharge,” “earache,” “flatulence,” “fracture,” “hemorrhage,” “incontinence,” “inflammation,” “itching,” “lesions,” “rash,” “spasms,” “swelling,” and “syncope”; 22 terms) and with known associations to COVID-19 (“bloating,” “blurry,” “congestion,” “cough,” “coughing,” “croup,” “diarrhea,” “dizzy,” “fainting,” “fever,” “pain,” “sneezing,” “strep,” “stuffy,” and “vomiting”; 15 terms) were queried to ascertain whether any significantly detected patterns in mental health search term activity were unique to and distinct from those pertaining to physical health. Note that each mental and physical health search term was considered independently in this study; in other words, composite scores aggregating the individual search term counts to create a composite score capturing total mental and physical health activity were not created. This decision was made because combining individual search terms with differential trends throughout the pandemic may attenuate these individual trends in the composite score such that the composite score may not be reflective of changes in specific mental or physical health symptoms, therefore making it uninformative.