Examination of a Bifactor Model of Obsessive-Compulsive Symptom Dimensions

Although obsessive-compulsive (OC) symptoms are observed along four dimensions (contamination, responsibility for harm, order/symmetry, and unacceptable thoughts), the structure of the dimensions remains unclear. The current study evaluated a bifactor model of OC symptoms among those with and without obsessive-compulsive disorder (OCD). The goals were (a) to evaluate if OC symptoms should be conceptualized as unidimensional or whether distinct dimensions should be interpreted and (b) to use structural equation modeling to examine the convergence of the OC dimensions above and beyond a general dimension with related criteria. Results revealed that a bifactor model fit the data well and that OC symptoms were influenced by a general dimension and by four dimensions. Measurement invariance of the bifactor model was also supported among those with and without OCD. However, the general OC dimension accounted for only half of the variability in OC symptoms, with the remaining variability accounted for by distinct dimensions. Despite evidence of multidimensionality, the dimensions were unreliable after covarying for the general OC dimension. However, the four dimensions did significantly converge with a latent OC spectrum factor above and beyond the general OC dimension. The implications of these findings for conceptualizing the structure of OCD are discussed.

Relapse Following Successful Intensive Treatment of Pediatric Obsessive-Compulsive Disorder

This case study describes the use of intensive exposure and response prevention (ERP) for the treatment of pediatric obsessive-compulsive disorder (OCD). The adolescent described in this report lives a long distance from treatment providers with expertise in managing severe OCD symptoms. Thus, he has to travel out of town for effective therapy. The treatment program results in substantial immediate benefits. However, gradual relapse is noted once treatment is over and the patient returns to his home environment. Obstacles to the accessibility of ERP for pediatric OCD, conducting successful treatment, and generalizing and maintaining gains are discussed with the aim of drawing attention to, and facilitating the prevention of, these difficulties. Suggestions for addressing the shortcomings highlighted by this case are presented.

Treatment of Obsessive Thoughts and Cognitive Rituals Using Exposure and Response Prevention

This case study describes the application of cognitive-behavioral therapy by exposure and response prevention (EX/RP) to a young man with obsessive-compulsive disorder (OCD) involving primarily obsessional thoughts and mental rituals. Although patients with primarily cognitive OCD symptoms have been previously considered treatment resistant, novel approaches to EX/RP have been developed and validated. Successful treatment of such symptoms requires a thorough and informed assessment. The theoretical and empirical basis for these procedures is described, along with a cognitive-behavioral analysis of the problem. The course of treatment, use of assessment data, and recommendations to clinicians are also discussed.

Research Review: Neuropsychological test performance in pediatric obsessive-compulsive disorder--a meta-analysis

BACKGROUND

Research into the neuropsychology of pediatric obsessive-compulsive disorder (OCD) reveals inconsistent results, limiting the ability to draw conclusions about possible neurocognitive deficits in youth with OCD. The aim of this study was to conduct a meta-analysis of the available literature.

METHODS

We identified 36 studies, of which 11 studies met inclusion criteria. Results were categorized into nine functional subdomains: planning, response inhibition/interference control, set shifting/cognitive flexibility, verbal memory, nonverbal memory, processing speed, working memory, visuospatial functions, and attention. For each domain, weighted pooled Hedges' g effect size was calculated using random model analyses.

RESULTS

Small effect sizes were found across all subdomains, none of which were found to be statistically significant.

DISCUSSION

Results indicate that youth with OCD do not exhibit noteworthy neuropsychological deficits. This is in line with recent suggestions that OCD may not be characterized by clinically meaningful neuropsychological impairments. However, the small number of available controlled studies highlights the urgent need for more neuropsychological research in this population, as well as for further exploration of the neurodevelopmental hypothesis in pediatric OCD. Finally, the relatively low persistence rates of OCD into adulthood should be taken under consideration, especially in the context of the putative neuropsychological performance differences between adult and pediatric OCD populations.

Neuropsychological investigations in obsessive-compulsive disorder: A systematic review of methodological challenges

The inconsistent nature of the neuropsychology literature pertaining to obsessive-compulsive disorder (OCD) has long been recognized. However, individual studies, systematic reviews, and recent meta-analytic reviews were unsuccessful in establishing a consensus regarding a disorder-specific neuropsychological profile. In an attempt to identify methodological factors that may contribute to the inconsistency that is characteristic of this body of research, a systematic review of methodological factors in studies comparing OCD patients and non-psychiatric controls on neuropsychological tests was conducted. This review covered 115 studies that included nearly 3500 patients. Results revealed a range of methodological weaknesses. Some of these weaknesses have been previously noted in the broader neuropsychological literature, while some are more specific to psychiatric disorders, and to OCD. These methodological shortcomings have the potential to hinder the identification of a specific neuropsychological profile associated with OCD as well as to obscure the association between neurocognitive dysfunctions and contemporary neurobiological models. Rectifying these weaknesses may facilitate replicability, and promote our ability to extract cogent, meaningful, and more unified inferences regarding the neuropsychology of OCD. To that end, we present a set of methodological recommendations to facilitate future neuropsychology research in psychiatric disorders in general, and in OCD in particular.

Uncertainty as an anxiety cue at high and low levels of threat

BACKGROUND AND OBJECTIVES

Intolerance of uncertainty and the overestimation of threat contribute to the maintenance of anxiety; however, the interaction between uncertainty and threat perception has not been examined empirically. The current study examined the extent to which explicitness of uncertainty is involved in perceptions of, and responses to, scenarios about threatening situations.

METHODS

A series of systematically varied scenarios were used to examine whether manipulating uncertainty (implicit vs. explicit) and threat level (high vs. low) altered the perception of a situation as anxiety-inducing. Undergraduate participants (n = 373) responded to vignettes about common situations (e.g., taking an elevator) with ratings of anxiety and desire to perform a safety behavior.

RESULTS

Results revealed that higher threat situations, and those in which uncertainty was made explicit, provoked higher ratings of anxiety and urge to perform a safety behavior. In addition, explicit uncertainty significantly increased anxiety and urge to perform a safety behavior at low, but not at high, levels of threat.

LIMITATIONS

Participants rated (via self-report) their hypothetical feelings as induced by vignettes, rather than actually experiencing these situations in vivo.

CONCLUSIONS

We found evidence for "uncertainty-based reasoning," in which an individual perceives a situation as more anxiety-provoking (and is more likely to have the urge to perform a safety behavior) when the uncertain aspects of a situation are obvious or explicit, than when such uncertainty is merely implied or tacit. Implications for the understanding of "uncertainty-based reasoning" are discussed.

Examining Attentional Bias in Scrupulosity: Null Findings From the Dot Probe Paradigm

Research consistently demonstrates that individuals with anxiety symptoms exhibit attentional biases toward threatening stimuli using various computer-based tasks. However, the presence of attentional biases across obsessive-compulsive symptom presentations has been mixed and requires clarification. This study was the first to use the dot probe paradigm to investigate the association between scrupulosity symptoms (obsessions and compulsions having to do with religion and morality) and selective attention to scrupulosity-relevant lexical stimuli. Contrary to hypotheses, individuals with higher levels of scrupulosity did not selectively attend (i.e., have faster reaction times) to scrupulosity-specific threat words (e.g., hell) more so than to general threat or neutral words. Various potential explanations for these null findings, as well as directions for future research, are discussed.

The effect of a couple-based treatment for OCD on intimate partners

BACKGROUND AND OBJECTIVES

This study investigated the effect of a couple-based cognitive behavioral therapy (CBT) for the treatment of obsessive-compulsive disorder (OCD) on the intimate partners of patients. Previous research has shown this intervention to be efficacious in reducing OCD symptoms and comorbidities in patients.

METHOD

In an open-treatment trial, 16 couples completed the 16-session manualized treatment, and were followed up 6- and 12-months post-treatment.

RESULTS

Multilevel modeling analyses were conducted to examine change over time, and results indicated that relative to baseline, partners showed improvements in relationship functioning, communication, and criticalness in the short-term, and maintained their gains in communication skills over the long-term.

LIMITATIONS

The non-controlled design and small sample size limit the certainty of the study's findings.

CONCLUSIONS

Overall, this investigation offers preliminary evidence that including intimate partners in couple-based CBT for OCD has no negative effects on partners, and in fact, can provide them with residual positive effects.

Secondary Psychometric Examination of the Dimensional Obsessive-Compulsive Scale: Classical Testing, Item Response Theory, and Differential Item Functioning

The Dimensional Obsessive-Compulsive Scale (DOCS) is a promising measure of obsessive-compulsive disorder (OCD) symptoms but has received minimal psychometric attention. We evaluated the utility and reliability of DOCS scores. The study included 832 students and 300 patients with OCD. Confirmatory factor analysis supported the originally proposed four-factor structure. DOCS total and subscale scores exhibited good to excellent internal consistency in both samples (α = .82 to α = .96). Patient DOCS total scores reduced substantially during treatment (t = 16.01, d = 1.02). DOCS total scores discriminated between students and patients (sensitivity = 0.76, 1 - specificity = 0.23). The measure did not exhibit gender-based differential item functioning as tested by Mantel-Haenszel chi-square tests. Expected response options for each item were plotted as a function of item response theory and demonstrated that DOCS scores incrementally discriminate OCD symptoms ranging from low to extremely high severity. Incremental differences in DOCS scores appear to represent unbiased and reliable differences in true OCD symptom severity.

How is the Beads Task related to intolerance of uncertainty in anxiety disorders?

Intolerance of uncertainty (IU) is a cognitive bias associated with anxiety disorders that has only been reliably measured using self-report instruments. The current study investigated relationships between a probabilistic inference task - the Beads Task - and self-report IU. Individuals with anxiety disorders (ANX) and non-anxious controls (NAC) completed self-report measures as well as the Beads Task at three levels of difficulty. The Beads Task successfully induced task-related uncertainty as the decision became more difficult. While the two groups did not differ on the observable performance related measures, the ANX group was significantly more distressed during the task than were the NACs. Moreover, among the ANX group, self-reported IU was correlated with draws to decision and distress during the task. The Beads Task appears to provoke distress associated with uncertainty for anxious individuals, rather than altering their behavioral responses; thus, clinical implications and avenues for future research are discussed.

Musical obsessions: a comprehensive review of neglected clinical phenomena

Intrusive musical imagery (IMI) consists of involuntarily recalled, short, looping fragments of melodies. Musical obsessions are distressing, impairing forms of IMI that merit investigation in their own right and, more generally, research into these phenomena may broaden our understanding of obsessive-compulsive disorder (OCD), which is phenomenologically and etiologically heterogeneous. We present the first comprehensive review of musical obsessions, based on the largest set of case descriptions ever assembled (N=96). Characteristics of musical obsessions are described and compared with normal IMI, musical hallucinations, and visual obsessional imagery. Assessment, differential diagnosis, comorbidity, etiologic hypotheses, and treatments are described. Musical obsessions may be under-diagnosed because they are not adequately assessed by current measures of OCD. Musical obsessions have been misdiagnosed as psychotic phenomena, which has led to ineffective treatment. Accurate diagnosis is important for appropriate treatment. Musical obsessions may respond to treatments that are not recommended for prototypic OCD symptoms.

Sensory intolerance: latent structure and psychopathologic correlates

BACKGROUND

Sensory intolerance refers to high levels of distress evoked by everyday sounds (e.g., sounds of people chewing) or commonplace tactile sensations (e.g., sticky or greasy substances). Sensory intolerance may be associated with obsessive-compulsive (OC) symptoms, OC-related phenomena, and other forms of psychopathology. Sensory intolerance is not included as a syndrome in current diagnostic systems, although preliminary research suggests that it might be a distinct syndrome.

OBJECTIVES

First, to investigate the latent structure of sensory intolerance in adults; that is, to investigate whether it is syndrome-like in nature, in which auditory and tactile sensory intolerance co-occur and are associated with impaired functioning. Second, to investigate the psychopathologic correlates of sensory intolerance. In particular, to investigate whether sensory intolerance is associated with OC-related phenomena, as suggested by previous research.

METHOD

A sample of 534 community-based participants were recruited via Amazon.com's Mechanical Turk program. Participants completed measures of sensory intolerance, OC-related phenomena, and general psychopathology.

RESULTS

Latent class analysis revealed two classes of individuals: those who were intolerant of both auditory and tactile stimuli (n=150), and those who were relatively undisturbed by auditory or tactile stimuli (n=384). Sensory-intolerant individuals, compared to those who were comparatively sensory tolerant, had greater scores on indices of general psychopathology, more severe OC symptoms, a higher likelihood of meeting caseness criteria for OC disorder, elevated scores on measures of OC-related dysfunctional beliefs, a greater tendency to report OC-related phenomena (e.g., a greater frequency of tics), and more impairment on indices of social and occupational functioning. Sensory-intolerant individuals had significantly higher scores on OC symptoms even after controlling for general psychopathology.

CONCLUSIONS

Consistent with recent research, these findings provide further evidence for a sensory intolerance syndrome. The findings provide a rationale for conducting future research for determining whether a sensory intolerance syndrome should be included in the diagnostic nomenclature.

An examination of obsessive-compulsive symptoms and dimensions using profile analysis via multidimensional scaling (PAMS)

Contemporary cognitive models of obsessive-compulsive disorder (OCD) emphasize the importance of various types of dysfunctional beliefs in contributing to OC symptoms, such as beliefs about excessive personal responsibility, perfectionism, and intolerance for uncertainty. The present study seeks to further our understanding of the role of these beliefs by identifying the common profiles of such beliefs, using profile analysis via multidimensional scaling (PAMS). In Study 1, a large student sample (N=4079) completed the 44-item obsessive beliefs questionnaire. One major profile, control of thoughts and perfectionism, was extracted. Study 2 examined profiles of the 87-item obsessive beliefs questionnaire in people with obsessive-compulsive disorder (OCD; n=398), other anxiety disorders (n=104), and a sample of undergraduate students (n=285). Inflated responsibility was a prominent subscale in the profiles of all three groups. Only control over thoughts was a unique subscale in the profile obtained for the OCD group, with this group having lower scores compared to the other groups. The results suggest that while inflated responsibility is a significant subscale in the profile of individuals with OCD, it is not a unique contributor; instead, control over thoughts is unique to OCD. The data, as well as recent research investigating obsessive beliefs, suggest the need to revise the contemporary cognitive model of OCD.

Phenomenology and correlates of insight in pediatric obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is marked by the presence of obsessions and/or compulsions that cause significant interference in an individual's life. Insight regarding symptoms in youth with OCD may affect accurate assessment, acceptance and motivation for treatment, tolerance of negative valence states (i.e., fear) and treatment outcome, so assessment of this construct and associated clinical characteristics is important. Accordingly, the current study sought to expand the literature on symptom insight by examining multi-informant ratings of insight from children, parents, and clinicians simultaneously and its relationship to varied clinical characteristics. One-hundred and ten treatment-seeking youth with a primary diagnosis of OCD, aged 6-17, participated in the study along with a parent/guardian. The nature of symptom conviction, fixity of ideas, and perceptions about the cause of the problems were important indicators in assessing child insight and resulted in a comprehensive, psychometrically-sound measure of insight. Insight was generally not strongly associated with clinical characteristics. Poor insight was moderately associated with less resistance of obsessive-compulsive symptoms, increased externalizing symptoms, and ordering symptoms. Overall, this study contributes further information into the nature and correlates of insight in youth with OCD, and provides a psychometrically sound approach for its assessment.

The sense of incompleteness as a motivator of obsessive-compulsive symptoms: an empirical analysis of concepts and correlates

Contemporary models of obsessive-compulsive disorder emphasize the importance of harm avoidance (HA) and related dysfunctional beliefs as motivators of obsessive-compulsive (OC) symptoms. Recently, there has been a resurgence of interest in Janet's (1908) concept of incompleteness (INC) as another potentially important motivator. Contemporary investigators define INC as the sense that one's actions, intentions, or experiences have not been properly achieved. Janet defined INC more broadly to include alexithymia, depersonalization, derealization, and impaired psychological mindedness. We conducted two studies to address four issues: (a) the clinical correlates of INC; (b) whether INC and HA are distinguishable constructs; (c) whether INC predicts OC symptoms after controlling for HA; and (d) the relative merits of broad versus narrow conceptualizations of INC. Study 1 was a meta-analysis of the clinical correlates of narrowly defined INC (16 studies, N=5,940). INC was correlated with all types of OC symptoms, and was more strongly correlated with OC symptoms than with general distress. Study 2 (N=534 nonclinical participants) showed that (a) INC and HA were strongly correlated but factor analytically distinguishable; (b) INC statistically predicted all types of OC symptoms even after controlling for HA; and (c) narrow INC was most strongly correlated with OC symptoms whereas broad INC was most strongly correlated with general distress. Although the findings are limited by being correlational in nature, they support the hypothesis that INC, especially in its narrow form, is a motivator of OC symptoms.

Prayer in Response to Negative Intrusive Thoughts: Closer Examination of a Religious Neutralizing Strategy

Few studies have systematically examined the covert neutralizing strategies that serve to maintain and exacerbate the frequency and distress related to intrusive thoughts. Given the lack of research in this area, this study aimed to highlight development and maintenance factors for one such strategy, compensatory prayer, to inform assessment and treatment of related obsessional phenomena. We used a multimethod approach to examine the predictors and function of prayer when it is used in response to negative intrusive thoughts. Participants were 85 undergraduate students (ages 18–55 years) who self-identified with a branch of Christianity. In addition to self-report measures, participants were administered an in vivo negative thought induction and were subsequently asked about their use of compensatory prayer behaviors. Results indicated that religiosity, intrinsic religious motivation, and moral thought–action fusion (TAF) positively predicted the use of prayer, with moral TAF emerging as a unique predictor and a complete mediator between religiosity and the use of prayer. Regarding the function of prayer, results indicated that when prayer is used maladaptively (i.e., negative coping style), it is associated with higher scores on religious measures and moral TAF, as well as more frequent engagement in prayer, and a greater reduction in anxiety postprayer. Surprisingly, likelihood TAF was not found to be related to the use or function of prayer. Results are discussed in terms of certain religious teachings and TAF-related beliefs, neurobiological explanations for our pattern of findings, and clinical implications for religious-related intrusive thoughts. Future directions and limitations are also discussed.

The practice of exposure therapy: relevance of cognitive-behavioral theory and extinction theory

Exposure therapy is the most effective psychological intervention for people with anxiety disorders. While many therapists learn how to implement exposure techniques through clinical training programs or instructional workshops, not all of these educational efforts include a focus on the theory underlying this treatment. The availability of treatment manuals providing step-by-step instructions for how to implement exposure makes it easier for clinicians to use these techniques with less training than they might otherwise receive. This raises questions regarding whether it is necessary to understand the theory behind the use of exposure. This article argues that knowledge of the relevant theory is crucial to being able to implement exposure therapy in ways that optimize both short- and long-term outcome. Specific ways in which theory is relevant to using exposure techniques are discussed.

Treating obsessive-compulsive disorder in intimate relationships: a pilot study of couple-based cognitive-behavior therapy

Although cognitive-behavioral therapy (CBT) involving exposure and response prevention (ERP) is an established treatment for obsessive-compulsive disorder (OCD), not all patients respond optimally, and some show relapse upon discontinuation. Research suggests that for OCD patients in close relationships, targeting relationship dynamics enhances the effects of CBT. In the present study, we developed and pilot tested a 16-session couple-based CBT program for patients with OCD and their romantic partners. This program included (a) partner-assisted ERP, (b) techniques targeting maladaptive relationship patterns focal to OCD (e.g., symptom accommodation), and (c) techniques targeting non OCD-related relationship stressors. OCD, related symptoms, and relationship functioning were assessed at baseline, immediately following treatment (posttest), and at 6- and 12-month follow-up. At posttest, substantial improvements in OCD symptoms, relationship functioning, and depression were observed. Improvements in OCD symptoms were maintained up to 1year. Results are compared to findings from studies of individual CBT for OCD and discussed in terms of the importance of addressing interpersonal processes that maintain OCD symptoms.

Just to be certain: Confirming the factor structure of the intolerance of uncertainty scale in patients with obsessive-compulsive disorder

Intolerance of uncertainty (IU) is a cognitive construct in obsessive-compulsive disorder (OCD); yet no studies exist confirming the factor structure of the most widely used measure of IU, the intolerance of uncertainty scale (IUS), in OCD patients. Moreover, no studies have examined how scores on this measure relate to OCD symptom dimensions. Accordingly, the present study examined a 12-item two-factor revised version of the IUS (IUS-12) in 205 OCD patients. Confirmatory factor analysis verified the scale's two-factor structure. The measure also demonstrated high internal consistency and the IUS-12 was correlated moderately with another self-report measure of IU. Finally, theoretically consistent and specific relationships emerged between the IUS-12 and OCD symptom dimensions. These findings are discussed in terms of implications for the assessment and treatment of OCD, and specifically how elevated scores on the IUS-12 subscales may be utilized to identify subtleties in the presentation of OCD-related problems with IU.