A cognitive theory of obsessions

Experiences of Obsessive-Compulsive Disorder: Activity, State, and Object Episodes

Obsessive-compulsive disorder (OCD) is a mental health problem characterized by persistent obsessions and compulsions. This article provides insights into experiences of OCD through a qualitative, thematic analysis performed on a set of interviews with people with OCD. Four themes were found as central in the participants' descriptions of OCD episodes: (a) space, (b) the body, (c) objects, and (d) interactions. The findings also show that episodes of OCD can be grouped into three broad categories: (a) activity episodes, which revolve around everyday tasks; (b) state episodes, which are concerned with the self and identity; and (c) object episodes, which are concerned with the effects of objects on the self. The relationship of this three-way classification of OCD episodes to existing cognitive models of OCD is discussed. The study also demonstrates the value of categorizing episodes, rather than people, into subtypes of OCD so that intra-participant variation can be highlighted.

Distress intolerance as a moderator of the relationship between daily stressors and affective symptoms: Tests of incremental and prospective relationships

BACKGROUND

Distress intolerance (DI) is conceptualized as an individual difference reflective of the ability to tolerate aversive psychological states. Although high DI has demonstrated cross-sectional associations with multiple forms of psychopathology, few studies have tested key facets of its theoretical conceptualization. Specifically, little research has been conducted on DI's theorized role as an incrementally valid prospective moderator of the relationship between daily stressful events and affective symptoms reflective of preoccupation with aversive internal (e.g., depression, worry) rather than external stimuli (e.g., social anxiety).

METHOD

A non-clinical sample (N = 147; 77% female; M age = 19.32) in which high DI individuals were oversampled was recruited. Participants completed baseline measures of DI and trait negative affect followed by six diary entries over a two-week period in which participants reported on daily stressors, negative affect, worry, depressive, and social anxiety symptoms.

RESULTS

Hierarchical linear models revealed that DI positively predicted depressive and worry, but not social anxiety symptoms, independent of daily stressors and negative affect. Further, a significant interaction effect was found such that the positive association between daily stressor(s) occurrence and daily worry was significant at high, but not low DI, and a similar trend-level interaction effect was observed for depressive symptoms. The interaction for social anxiety symptoms was non-significant LIMITATIONS: Utilization of a non-clinical sample precludes generalization of results to clinical samples. Only self-reported DI was assessed, limiting conclusions to perceived as opposed to behaviorally-indexed DI.

CONCLUSIONS

Results largely supported DI's theoretical conceptualization as an incrementally valid moderator of stress responding with relevance to particular affective symptoms.

Appraisals of and recommendations for managing intrusive thoughts: An empirical investigation

The present study investigated strategies for managing intrusive thoughts. Eighty undergraduate students read vignettes of intrusive thoughts - blasphemous, sexual, and violent - which varied in frequency of the thought (high or low) and who experienced the thought (self or other). Appraisal ratings of thoughts were completed and participants completed a response strategy survey where they indicated how much they would endorse various methods for dealing with the thoughts. Some response strategies were theorized to help with intrusive thoughts and some were theorized to be unhelpful. Measures of obsessive-compulsive tendencies were completed to determine relationships between beliefs and appraisals as well as responses to the intrusive thoughts. Results indicated the more distressing a thought was perceived to be, the more likely participants were to recommend unhelpful strategies. Conversely, the less distressing the thought was, the more likely participants were to recommend helpful strategies. Ratings of distress and patterns of responses were related to obsessive-compulsive beliefs as well. Findings are discussed in terms of their relationship to the cognitive behavioral model of OCD, intrusive thoughts, and how future work may serve to educate and reduce stigma related to these common yet distressing experiences.

[Mindfulness-based interventions in obsessive-compulsive disorder: Mechanisms of action and presentation of a pilot study]

Obsessive-compulsive disorder (OCD) is a frequent and severe disease, potentially inducing a major impairment for the patient and burden for their family. Recent research in psychiatry and neuroscience have led to better comprehension of the disease's mechanisms and helped to improve its treatment. However, a large proportion of patients have refractory symptoms, including for traditional cognitive and behavioral therapy by exposure and response prevention (ERP), leading clinicians to look for new treatments. Mindfulness-based interventions (MBI) are a new type of approach, initially based on Buddhist meditation, which aims to provide better consciousness of the present moment. It has been successfully developed in some psychiatric diseases and other general medical conditions such as chronic pain. The two main programs using mindfulness meditation, Mindfulness-based stress reduction (MBSR) and Mindfulness-based cognitive therapy (MBCT), have shown effectiveness for the reduction of depressive and anxiety symptoms and relapses of depressive episodes in unipolar depression. It has no side effects and is well tolerated by patients. Its action relies on the specific correction of cognitive deficits in attention, emotion regulation and executive functions which are shared by OCD, GAD and depression. For OCD, we make the hypothesis that Mindfulness-Based Interventions could reduce the cognitive bias specifically existing in this pathology, such as dysfunctional beliefs, and therefore improve the symptoms. This article first reviews the existing literature on clinical trials involving Mindfulness-Based Interventions in OCD which comprises a small number of clinical studies based on very different types of protocols. At this time, and due to the lack of gold-standard studies with a large number of patients, no proof of the efficiency of mindfulness-based interventions in OCD has been shown. In a second section, following our hypothesis on the mechanisms of specific and non-specific action of this therapy in OCD, we propose a cognitive model of mindfulness-based therapy action in OCD involving the correction of OCD's cognitive bias. In this model, mindfulness-based therapy is supposed to treat specifically the cognitive aspects of the disease, while ERP is focused on its behavioral part. Then we present a clinical study aiming to prove the feasibility and the interest of the use of mindfulness in OCD, carried out in two different clinical centers. One of them used MBCT while the second used MBSR. Its results show the feasibility of mindfulness-based therapy in OCD patients and tend to prove that it could be more effective in young patients suffering from less severe forms of OCD. In parallel, attention tests and fMRI scans were done at the beginning and at the end of the therapy. Their results will be published separately. We also discuss the putative role of a specific form of MBCT adapted for OCD, specifically for its benefits in psychoeducation, which could reduce the dysfunctional beliefs present in OCD patients. Finally, we propose a therapeutic strategy in which the MBCT could complement the classical ERP therapy, as a "maintenance" treatment, aiming to extend the relapse of OCD symptoms. This article is a step further in the use of mindfulness-based therapy for OCD which could be added to the existing treatments reducing the patient's symptoms and improving their quality of life.

The Termination of Checking and the Role of Just Right Feelings: A Study of Obsessional Checkers Compared with Anxious and Non-clinical Controls

Background: Repeated checking in OCD can be understood from a cognitive perspective as the motivated need to achieve certainty about the outcome of a potentially risky action, leading to the application of Elevated Evidence Requirements (EER) and overuse of subjective criteria. Method: Twenty-four obsessional checkers, 22 anxious controls, and 26 non-clinical controls were interviewed about and rated recent episodes where they felt (a) they needed to check and (b) checked mainly out of habit (i.e. not obsessionally). Results: Both subjective and objective criteria were rated as significantly more important in obsessional checkers than in controls; obsessional checkers also used more criteria overall for the termination of the check, and rated more criteria as “extremely important” than the control groups. The termination of the check was rated as more effortful for obsessional checkers than for the comparison groups. Analysis of the interview data was consistent with the ratings. Feelings of “rightness” were associated with the termination of a check for obsessional checkers but not for controls. Conclusion: Results were consistent with the proposal that the use of “just right feelings” to terminate checking are related to EER.

Cognitive-Behavioral Therapy: Nature and Relation to Non-Cognitive Behavioral Therapy

Since the introduction of Beck's cognitive theory of emotional disorders, and their treatment with psychotherapy, cognitive-behavioral approaches have become the most extensively researched psychological treatment for a wide variety of disorders. Despite this, the relative contribution of cognitive to behavioral approaches to treatment are poorly understood and the mechanistic role of cognitive change in therapy is widely debated. We critically review this literature, focusing on the mechanistic role of cognitive change across cognitive and behavioral therapies for depressive and anxiety disorders.

The relationship between clinical characteristics, metacognitive appraisals, and cognitive insight in patients with obsessive-compulsive disorder

BACKGROUND

Cognitive insight, a recently developed insight measure, refers to metacognitive processes of the re-evaluation and correction of distorted beliefs and misinterpretations. However, to the best of the authors' knowledge, no study has specifically examined cognitive insight, demographics, psychopathological variables, and distorted beliefs in OCD.

AIM

The aim of this research was to examine links between cognitive insight and demographics, clinical factors, and distorted beliefs among patients with OCD.

METHOD

Eighty-four consecutive outpatients with a diagnosis of OCD underwent a detailed clinical assessment for OCD, including the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Beck Cognitive Insight Scale (BCIS), Thought-Action Fusion Scale (TAFS), White Bear Thought Suppression Inventory, Metacognition Questioniarre-30 (MCQ-30), and a sociodemographic questionnaire. In addition, 82 control subjects matched for age, education, and gender were tested.

RESULTS

BCIS-self-certainty scores were all substantially higher in subjects with remitted and unremitted OCD than in healthy comparison subjects, while BCIS-composite scores were significantly lower in both patient groups than controls. Obsession and compulsion severity had significant effects on BCIS scores. In addition, it was found that the specific symptoms were linked to self-certainty scores. Self-reflectiveness and composite scores had positive correlations with the sub-scale scores of the MCQ-30, while the TAF-morality score was positively correlated with self-certainty scores.

CONCLUSION

The results demonstrated poor cognitive insight among remitted and unremitted OCD patients. In addition, the present study suggested significant associations between sociodemographic and clinical features and dysfunctional appraisals. Cognitive-behavioural techniques aimed at enhancing cognitive insight may be beneficial for patients with OCD, particularly patients who have prominent dysfunctional beliefs.

Patients With Obsessive-Compulsive Disorder Check Excessively in Response to Mild Uncertainty

Patients with obsessive-compulsive disorder (OCD) not only respond to obsessions with perseverative checking, but also engage in more general checking, irrespective of their obsessive concerns. This study investigated whether general checking is specific to OCD and exacerbated when only mild uncertainty is induced. Thirty-one patients with OCD, 26 anxiety- and 31 healthy controls performed a visual search task with eye-tracking and indicated in 50 search displays whether a target was "present" or "absent". Target-present trials were unambiguous, whereas target-absent trials induced mild uncertainty, because participants had to rely on not overlooking the target. Checking behavior was measured by assessing search time and the number of fixations, measured with an eye-tracker. Results showed that in both target-present and target-absent trials patients with OCD searched longer and made more fixations than healthy and anxiety controls. However, the difference in checking behavior between patients with OCD and the control groups was larger in target-absent trials (where mild uncertainty was induced). Anxiety and healthy controls did not differ in checking behavior. Thus, mild uncertainty appears to specifically promote checking in patients with OCD, which has implications for treatment.

The role of habit in compulsivity

Compulsivity has been recently characterized as a manifestation of an imbalance between the brain׳s goal-directed and habit-learning systems. Habits are perhaps the most fundamental building block of animal learning, and it is therefore unsurprising that there are multiple ways in which the development and execution of habits can be promoted/discouraged. Delineating these neurocognitive routes may be critical to understanding if and how habits contribute to the many faces of compulsivity observed across a range of psychiatric disorders. In this review, we distinguish the contribution of excessive stimulus-response habit learning from that of deficient goal-directed control over action and response inhibition, and discuss the role of stress and anxiety as likely contributors to the transition from goal-directed action to habit. To this end, behavioural, pharmacological, neurobiological and clinical evidence are synthesised and a hypothesis is formulated to capture how habits fit into a model of compulsivity as a trans-diagnostic psychiatric trait.

Where does obsessive-compulsive disorder belong in DSM-V?

A reclassification of obsessive-compulsive disorder (OCD) into a new diagnostic category spectrum of "obsessive-compulsive spectrum disorders" (OCSDs) has recently been proposed, with considerable debate, for the forthcoming Diagnostic and Statistical Manual-Fifth Edition (DSM-V). This paper provides a critical analysis of the available empirical data regarding this conceptual and nosological shift. Specifically, we review research on shared commonalities and differences between OCD and the putative OCSDs in relation to their clinical presentation, phenotype, neurobiology, and treatment response. We conclude that a reclassification of OCD into a separate OCSD spectrum is premature and not supported by the currently available data.

Obsessive-compulsive symptoms and attentional bias: An eye-tracking methodology

BACKGROUND AND OBJECTIVES

Cognitive models suggest that attentional biases are integral in the maintenance of obsessive-compulsive symptoms (OCS). Such biases have been established experimentally in anxiety disorders; however, the evidence is unclear in Obsessive Compulsive disorder (OCD). In the present study, an eye-tracking methodology was employed to explore attentional biases in relation to OCS.

METHODS

A convenience sample of 85 community volunteers was assessed on OCS using the Yale-Brown Obsessive Compulsive Scale-self report. Participants completed an eye-tracking paradigm where they were exposed to OCD, Aversive and Neutral visual stimuli. Indices of attentional bias were derived from the eye-tracking data.

RESULTS

Simple linear regressions were performed with OCS severity as the predictor and eye-tracking measures of the different attentional biases for each of the three stimuli types were the criterion variables. Findings revealed that OCS severity moderately predicted greater frequency and duration of fixations on OCD stimuli, which reflect the maintenance attentional bias. No significant results were found in support of other biases.

LIMITATIONS

Interpretations based on a non-clinical sample limit the generalisability of the conclusions, although use of such samples in OCD research has been found to be comparable to clinical populations. Future research would include both clinical and sub-clinical participants.

CONCLUSIONS

Results provide some support for the theory of maintained attention in OCD attentional biases, as opposed to vigilance theory. Individuals with greater OCS do not orient to OCD stimuli any faster than individuals with lower OCS, but once a threat is identified, these individuals allocate more attention to OCS-relevant stimuli..

The structure of obsessive compulsive symptoms and beliefs: A correspondence and biplot analysis

Research has suggested that obsessive-compulsive (OC) beliefs are differentially predictive of OC symptom dimensions. One additional way in which beliefs and symptoms may be related is by severity; that is, the role of beliefs may vary as a function of symptom severity. In order to evaluate this possibility, correspondence analysis with biplot was applied to evaluate the association between OC beliefs and OC symptom severity across three subsamples, individuals with obsessive-compulsive disorder (OCD; N=398), individuals with anxiety disorders (N=104), and undergraduate students (N=285). To do so, we generated five row categories of symptom severity and six columns based on the Obsessive Compulsive Beliefs Questionnaire (OBQ) for three subsamples. Unlike factor analyses of inter-variable correlations (or covariances), the CA-biplot paradigm calibrates simultaneously row and column information and estimates dimensional coordinates (analogous to factor loadings) separately for rows and columns. We used the first two dimensions from each subsample because they accounted for most variance (on average 89%) so as to construct a hypothetical plane with them. Then, we visually inspected associations among five severity categories (rows) and six OBQ subscales (columns) in the plane and also calculated their correlations. The visual configurations and numerical correlations were consistent across three subsamples, indicating that inflated responsibility was significantly associated with OC symptoms, but only for those with the least severe symptoms. Importance and control of thoughts were associated with OC symptoms across all levels of symptom severity. The implications of these findings for the cognitive model of OCD are considered.

Cognitive Dissonance About Thought-Action Fusion Beliefs Improves and Maintains the Effects of Thought-Action Fusion-Specific Psychoeducation

The effects of psychoeducation on thought-action fusion (TAF) beliefs are understudied. We tested whether adding mock electroencephalography (EEG)-based computer trials that induce cognitive dissonance about TAF beliefs, prior to TAF-specific psychoeducation, would enhance and maintain the reduction of TAF beliefs. An unselected sample of 140 Singaporean undergraduates (89 females, 51 males) was randomly assigned to a combined intervention, TAF-specific psychoeducation-only, or control group. Self-report measures of TAF beliefs and cognitive dissonance about TAF beliefs were administered 4 times in the initial session, and once at 1-month follow-up. Findings included the following: (a) greatest cognitive dissonance about TAF beliefs in the initial session with the combined intervention; (b) greater reduction in TAF beliefs in the initial session in both intervention groups, compared with the control group; and (c) incremental reduction in TAF beliefs in the initial session and maintenance at 1-month follow-up with the combined intervention. Cognitive dissonance should be investigated extensively in other aspects of cognitive behavioral therapy (CBT) procedures for TAF beliefs (e.g., behavioral experiments, exposure, and response prevention) to determine whether it contributes to therapeutic change with these techniques. Our combined intervention procedure should also be examined for relevant psychopathology (e.g., obsessive-compulsive symptoms).

The Association of Anger with Symptom Subtypes in Severe Obsessive-Compulsive Disorder Outpatients

BACKGROUND

Despite the theoretical and clinical relevance of psychopathological dimensions in obsessive-compulsive disorder (OCD), no studies to date have investigated their possible association with obsession subtypes. Thus, we aimed to examine whether, in OCD patients, anger and other psychopathological dimensions are associated with specific obsession subtypes.

METHODS

We consecutively recruited 57 first-visit OCD patients (66.7% female, mean age 34 years) at our Psychiatric Outpatient Clinic. We used the point biserial coefficient (rpbi) to measure the correlation between psychopathological dimensions and obsession subtypes.

RESULTS

We found significant correlations (p < 0.05) between the following: (1) anger/aggressiveness dimension and aggressive, contamination, and sexual obsessions; (2) apprehension/fear dimension and contamination, religious, and somatic obsessions; (3) sadness/demoralization dimension and contamination and somatic obsessions; (4) impulsivity dimension and aggressive and sexual obsessions, and (5) somatic concern/somatization dimension and contamination and somatic obsessions. We also found that OCD patients with comorbid obsessive-compulsive personality disorder--but not schizotypal or histrionic disorders--showed higher levels (p < 0.05) of obsessiveness/iterativity and anger/aggressiveness than OCD patients without the personality disorder.

CONCLUSIONS

Anger and other psychopathological dimensions seem to be linked with specific obsession subtypes in OCD patients, suggesting an association between these dimensions and OCD.

Clinical Feedback About Empirically Supported Treatments for Obsessive-Compulsive Disorder

Previous evidence for the treatment of obsessive-compulsive disorder (OCD) has been derived principally from randomized controlled trials. As such, evidence about the treatment of OCD has unilaterally flowed from researchers to clinicians. Despite often having decades of experience treating OCD, clinicians' feedback on their clinical observations in using these treatments has not been solicited. The current study contacted clinicians for their clinical observations on empirically supported treatments for OCD to identify commonly used cognitive-behavioral techniques and their limitations in their practices. One hundred eighty-one psychotherapists completed an online survey. The average participant practiced psychotherapy for 15 years, worked in private practice, held a doctorate, and treated an average of 25 clients with OCD in their lifetime. In regard to the most common techniques, behavioral strategies involving exposure to a feared outcome and prevention of a compulsive ritual were the most frequent group of interventions, followed by techniques that attempted to identify and challenge irrational thoughts. However, the majority of participants also reported incorporating mindfulness or acceptance-based methods. Based on therapists' reports, the most common barriers to the efficacy of cognitive-behavioral interventions included limited premorbid functioning, chaotic lifestyles, controlling and critical families, OCD symptom severity, OCD symptom chronicity, and comorbidities. This study provides insight into common practices and limitations in clinical practice to inform future clinically relevant treatment research.

Relationship Obsessive-Compulsive Disorder: Interference, Symptoms, and Maladaptive Beliefs

BACKGROUND

Obsessive preoccupation, doubts, and compulsive behaviors focusing on one's romantic relationship and partner are receiving increasing clinical, theoretical, and empirical attention. Commonly referred to as relationship obsessive-compulsive disorder (ROCD), such symptoms have been linked with decreased relational and sexual functioning and lower mood, even after controlling for other obsessive-compulsive disorder (OCD) symptoms. To date, however, these symptoms have been studied in community samples alone. In the present study, we compared levels of interference, OCD, and mood symptoms between clinical participants with ROCD, OCD, and community controls. We also examined group differences in maladaptive beliefs previously linked with OCD and ROCD.

METHOD

Participants included 22 ROCD clients, 22 OCD clients, and 28 community controls. The Mini International Neuropsychiatric Interview was used to attain clinical diagnoses of OCD and ROCD. The Yale-Brown Obsessive-Compulsive Scale was used to evaluate primary-symptoms severity. All participants completed measures of symptoms and dysfunctional beliefs.

RESULTS

ROCD clients reported more severe ROCD symptoms than the OCD and control groups. ROCD and OCD clients did not differ in severity of their -primary-symptoms. ROCD clients scored higher than the other groups on maladaptive OCD-related and relationship-related beliefs. Finally, ROCD clients showed more severe depression symptoms than community controls.

CONCLUSION

ROCD is a disabling presentation of OCD that warrants research attention. Maladaptive OCD-related and relationship-related beliefs may be implicated in the development and maintenance of ROCD.

The Role of Magical Thinking, Religiosity and Thought-Control Strategies in Obsessive-Compulsive Symptoms in a Turkish Adult Sample

Background: It has been suggested that magical thinking is related to both obsessions and compulsions in obsessive-compulsive disorder (OCD). Recent studies have indicated the significant relationship between level of religiosity and beliefs about the importance and need to control unwanted thoughts in OCD. People also use diverse strategies to control their unwanted thoughts. Aims: The present study aimed to examine the interrelationships between magical thinking and worry and punishment as thought-control strategies in mediating the relationship between religiosity and obsessive-compulsive (OC) symptoms in a Turkish sample. Methods: The sample of the present study was comprised of 179 non-clinical, community-based participants who completed measures of OC symptoms (measured with the Obsessive Compulsive Inventory — Revised), magical thinking (measured with the Magical Ideation Scale), religiosity, and thought-control strategies (measured with the Thought Control Questionnaire). Results: Both worry and punishment as thought-control strategies and magical thinking mediated the links between religiosity and OC symptoms. Furthermore, the relationship between religiosity and OC symptoms was mediated by magical thinking through punishment and worry. Conclusions: Findings pointing out the mediating role of magical thinking through punishment and worry in the relationship between religiosity and OC symptoms are novel and need to be replicated in future studies.

A Framework for Understanding the Emerging Role of Corticolimbic-Ventral Striatal Networks in OCD-Associated Repetitive Behaviors

Significant interest in the mechanistic underpinnings of obsessive-compulsive disorder (OCD) has fueled research on the neural origins of compulsive behaviors. Converging clinical and preclinical evidence suggests that abnormal repetitive behaviors are driven by dysfunction in cortico-striatal-thalamic-cortical (CSTC) circuits. These findings suggest that compulsive behaviors arise, in part, from aberrant communication between lateral orbitofrontal cortex (OFC) and dorsal striatum. An important body of work focused on the role of this network in OCD has been instrumental to progress in the field. Disease models focused primarily on these regions, however, fail to capture an important aspect of the disorder: affective dysregulation. High levels of anxiety are extremely prevalent in OCD, as is comorbidity with major depressive disorder. Furthermore, deficits in processing rewards and abnormalities in processing emotional stimuli are suggestive of aberrant encoding of affective information. Accordingly, OCD can be partially characterized as a disease in which behavioral selection is corrupted by exaggerated or dysregulated emotional states. This suggests that the networks producing OCD symptoms likely expand beyond traditional lateral OFC and dorsal striatum circuit models, and highlights the need to cast a wider net in our investigation of the circuits involved in generating and sustaining OCD symptoms. Here, we address the emerging role of medial OFC, amygdala, and ventral tegmental area projections to the ventral striatum (VS) in OCD pathophysiology. The VS receives strong innervation from these affect and reward processing regions, and is therefore poised to integrate information crucial to the generation of compulsive behaviors. Though it complements functions of dorsal striatum and lateral OFC, this corticolimbic-VS network is less commonly explored as a potential source of the pathology underlying OCD. In this review, we discuss this network's potential role as a locus of OCD pathology and effective treatment.

Partner-focused obsessions and self-esteem: An experimental investigation

BACKGROUND

Relationship-related obsessive-compulsive phenomena (ROCD) are encountered frequently in the clinic, and involve severe consequences to personal and relational well-being. One common presentation of ROCD involves disabling preoccupation and doubts focusing on intimate partner's flaws (partner-focused obsessions). It was previously suggested that individuals perceiving their partner's failures or flaws as reflecting on their own self-worth may be more sensitive to intrusive thoughts pertaining to their partner's qualities and characteristics. In the current studies, we assessed the link between partner-focused OC symptoms and self-esteem contingent on partner-value.

METHODS

In two studies we assessed the impact of experimentally induced partner-focused intrusions on self-esteem. In Study 1, we assessed individuals' self-esteem after one of three primes: (a) intrusion about one's partner comparing unfavorably with others of the same sex (i.e., alternative partners), (b) intrusion about one's partner comparing unfavorably to oneself, (c) and a neutral prime. In study 2, we tried to replicate Study 1 using a pre-post design and also examine whether favorable intrusions of one's partner would have an opposite effect on self-esteem than unfavorable intrusions.

RESULTS

Compared with the other groups, participants who were primed with intrusions of their partner being unfavorably compared to others reported lower self-esteem, but only if they had high levels of partner-focused symptoms. Favorable intrusions of partner to others did not have a positive effect on self-esteem among individuals with high levels of partner-focused symptoms.

CONCLUSIONS

Partner-value self-sensitivity may be one of the perpetuating mechanisms involved in partner-focused OC phenomena.

Fear of self, doubt and obsessive compulsive symptoms

BACKGROUND AND OBJECTIVES

Following observations in the literature that obsessions often contain or imply negative evaluative information about the self, Aardema et al. (2013) recently developed a measure of feared-self relevant to OCD. The current study aimed to provide further examination of the relevance of such feared self-beliefs to obsessive compulsive processes - in particular whether they partially underlie doubt in OCD-relevant situations.

METHOD

Nonclinical participants (N = 463; 291 females; Mage = 25.17, SD = 7.47), were presented with three vignettes, related to washing, checking and non-OCD relevant themes, which assessed doubt through providing alternating sensory and possibility-based information.

RESULTS

Higher levels of OCD symptoms and feared-self beliefs both significantly predicted both higher baseline levels of doubt and greater fluctuation in levels of doubt in both the contamination and checking scenarios, and to a much lesser extent in the control scenario. Feared-self beliefs did not predict fluctuation in doubt over-and-above OCD symptoms, consistent with a mediation model.

LIMITATIONS

The main limitation was the use of a non-clinical sample, although this allowed sufficient participant numbers to test hypotheses.

CONCLUSIONS

The findings provided further experimental support for reasoning processes in OCD, and suggested that feared self-beliefs may make individuals vulnerable to experiencing doubt. Additionally, these results suggested that individuals with high OCD symptoms and those with high feared self-beliefs are unable to recognise the improbable nature of possibility-based statements. Implications for treatment and theory are discussed.

Discovering what is hidden: The role of non-ritualized covert neutralizing strategies in Obsessive-Compulsive Disorder

BACKGROUND AND OBJECTIVES

Neutralizing strategies are secondary to obsessions and an additional cause of distress and interference, but they have received little attention in theories and research, especially the non-ritualized covert strategies. This study focuses on the comparative impact of non-ritualized covert and compulsive-overt strategies in the course of OCD.

METHODS

Eighty-two OCD adult patients completed measures assessing distress, interference, appraisals and overt and covert neutralizing strategies to control obsessions. Thirty-eight patients who had completed cognitive therapy were assessed again after treatment.

RESULTS

Only overt compulsions are associated with OCD severity. Nonetheless, considering the main symptom dimension, covert strategies are also associated with severity in patients with moral-based obsessions. Patients who used covert strategies more frequently, compared to those who use them less, reported more sadness, guilt, control importance, interference, and dysfunctional appraisals. Regarding the overt strategies, patients who used them more reported more anxiety and ascribed more personal meaning to their obsessions than the patients who used them less. After treatment, recovered patients decreased their use of both covert and overt strategies, while non-recovered patients did not. There was a higher rate of non-recovered patients among those who used more non-ritualized covert strategies before treatment.

LIMITATIONS

Emotions and appraisals were assessed with a single item. OCD symptom dimensions were only assessed by the Obsessive-Compulsive Inventory.

CONCLUSIONS

In addition to studying overt compulsions, the impact of covert neutralizing strategies on the OCD course and severity warrants more in-depth study.

Exposure to unwanted intrusions, neutralizing and their effects on self-worth and obsessive-compulsive phenomena

BACKGROUND

Although there is a growing body of literature to support the importance of understanding self processes in the experience of obsessive-compulsive disorder (OCD), no experimental research has directly examined the relationship between self-construals and phenomena central to OCD. The current study examined the effect that unwanted intrusions and neutralizing responses have on self-worth, distress and urge to neutralize.

METHODS

After listening to repeated audio recordings of idiosyncratic unwanted intrusions, a combined nonclinical and clinical OCD sample were asked to respond with either their chosen neutralizing strategy (experimental) or a refocus counting strategy (control). Each condition comprised of a 12-min responding period (respond) followed by an equivalent non-response period (listen). Participants completed each condition, and were randomly allocated into the condition completed first. Ratings of discomfort, urge to neutralize, and self-worth were measured throughout.

RESULTS

Neutralizing and refocussing responses were both associated with decreases in discomfort and higher self-worth. The expected rebound effect for discomfort and urge to neutralize for the listen period after neutralizing was found.

LIMITATIONS

Methodological problems lead to missing data, although this was corrected with the use of Multi Level Modelling (MLM) analysis on a combined sample. The small clinical sample meant that comparison between the two populations was not possible.

CONCLUSIONS

Findings support cognitive accounts that neutralizing is involved in the development and maintenance of OCD, and suggest that neutralizing is a purposeful response aimed to help reinstate self-worth. Implications and directions for future research are discussed.

Incompleteness, aesthetic sensitivity, and the obsessive-compulsive need for symmetry

BACKGROUND AND OBJECTIVES

The "need for symmetry" is a well recognized yet little understood feature of obsessive-compulsive (OC) experience. In light of the strong associations between the OC-related trait of incompleteness and symmetry-related behaviors and symptoms, and between perceptual symmetry and aesthetic judgments, this study examined whether trait incompleteness is associated with enhanced natural aesthetic skill and/or aesthetic sensitivity, particularly as they pertain to visual symmetry.

METHODS

A quasi-experimental design was used to compare the responses of nonclinical individuals with high versus average levels of trait incompleteness on self-report measures and two performance measures of aesthetic judgment.

RESULTS

Compared to controls, participants high in incompleteness reported higher levels of self-perceived symmetry-related concerns and behaviors, and displayed greater aesthetic sensitivity in the form of substantially heightened preferences for symmetry in images. Contrary to the hypothesis relating to aesthetic skill, however, the two groups did not differ in their capacity to estimate accurately the objective aesthetic value of images. Nor did they differ in self-reported aesthetics interests and background.

LIMITATIONS

A clinical sample was not included.

CONCLUSIONS

Findings provide evidence that high trait incompleteness is associated not just with symptomatic symmetry-related concerns but with a nonspecific heightened preference for visual symmetry. Conceptual implications are discussed, particularly the potential value of the perceptual fluency theory of symmetry and aesthetic response for explaining the association between incompleteness and symmetry preferences and symptoms.

Highly efficacious cognitive-coping therapy for overt or covert compulsions

Pharmacotherapy and cognitive-behavioral therapy (CBT) present limitations when they are used to treat obsessive-compulsive disorder (OCD), a severe and debilitating psychiatric disorder. To search for more efficacious treatment, we investigated the effects of pharmacotherapy plus cognitive-coping therapy (pCCT) on adult OCD patients with overt or covert compulsions. Two hundred and fifteen OCD patients were randomized into pharmacotherapy plus psychological support (PPS, n=107) and pCCT (n=108). The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) was used to measure severity of symptoms in the OCD patients. The Y-BOCS scores were significantly lower in pCCT than in PPS in both acute term (<3 months) and long-term follow-up. In pCCT, severity of symptoms was not different between those with covert compulsions and those with overt compulsions, but was significantly reduced at any post-treatment time-point. Y-BOCS scores in the two subtype compulsions were significantly lower in pCCT than in PPS at any post-treatpost-treatment time-point. Compared with PPS, effect size, response rate and remission rate were significantly higher in pCCT. Our findings corroborated with the hypothesis that pCCT could efficaciously treat OCD with overt compulsions or covert compulsion, suggesting that pCCT might be a potential option for adult OCD.

Remote cognitive-behavior therapy for obsessive-compulsive symptoms: A meta-analysis

Obsessive-compulsive disorder (OCD) is a chronic mental health condition that results in a significant societal burden. Remote treatments do not require the patient to attend traditional face-to-face treatment services and can be used as a way to overcome barriers to accessing face-to-face treatment. The aim of the current study was to synthesize the current literature on remote treatment for OCD using a meta-analytic approach. Relevant articles were identified through an electronic database search and the references of previously completed reviews on the topic of remote treatment for OCD were also reviewed. Eighteen studies (n=823; mean age=31.20 (SD=10.36); 56.2% female) were included in the meta-analysis. Within-group findings indicate that remote treatment for OCD produces a decrease in symptoms of a large magnitude (g=1.17; 95% CI: 0.91-1.43). Between-group findings indicate that remote treatment for OCD is more effective than control (g=1.06; 95% CI: 0.68-1.45) and outcomes are not meaningfully different from face-to-face treatment (g=-0.21; 95% CI: -0.43-0.02). Those methodologies that are low intensity produce a decrease in symptoms of a large magnitude (g=1.36, 95% CI: 1.00-1.72), as do higher intensity treatments (g=1.64, 95% CI: 1.33-1.95). These findings have important implications for the development of stepped-care treatments, which may be able to be delivered in a purely remote fashion.

Symptom Dimensions in Obsessive-Compulsive Disorder and Obsessive Beliefs

BACKGROUND

Obsessive-compulsive disorder (OCD) is a heterogeneous condition with a few major symptom dimensions. These symptom dimensions are thought to have unique clinical and neurobiological correlates. There seems to be a specific relation between OCD symptom dimensions and obsessive beliefs, but the findings are not consistent across studies. There is also a paucity of literature from culturally diverse settings. One of the reasons for the varied findings could be due to the method employed in measuring OCD symptoms.

MATERIALS AND METHODS

In this study, we examined the relation between symptom dimensions and obsessive beliefs using the Dimensional Yale-Brown Obsessive-Compulsive Scale and the Obsessive Beliefs Questionnaire respectively in 75 patients with Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition OCD.

RESULTS

Perfectionism predicted both aggressive and symmetry dimensions whereas responsibility beliefs predicted sexual and religious dimensions.

CONCLUSIONS

The findings suggest that certain obsessive beliefs predicted certain OCD symptom dimensions, but results are not entirely consistent with the published literature suggesting the possibility of cross-cultural variations. That the symptom dimensions have unique belief domains support the argument that symptom dimensions could be targeted to reduce the heterogeneity in etiological and treatment studies of OCD. Therapeutic interventions may have to aim at modifying unique belief domains underlying certain symptom dimensions rather than having generic cognitive-behavioral strategies.

Anxiety control and metacognitive beliefs mediate the relationship between inflated responsibility and obsessive compulsive symptoms

Research has indicated that beliefs about inflated responsibility, beliefs about perceived control over anxiety-related events and reactions (anxiety control) and metacognitive beliefs about the need to control thoughts are associated with obsessive compulsive symptoms. In the current study we tested a mediation model of the interactions between these variables in predicting obsessive compulsive symptoms. Thirty-seven individuals with obsessive compulsive disorder and 31 controls completed the following self-report instruments: the Responsibility Attitude Scale, the Anxiety Control Scale, the Beliefs about Need to Control Thoughts sub-scale of the Metacognitions Questionnaire 30, and the Padua Inventory. Mann-Whitney U tests revealed that participants in the clinical group scored significantly higher than those in the non-clinical group on all variables. In the mediation model we found that the relationship between beliefs about inflated responsibility and obsessive compulsive symptoms was fully mediated by anxiety control and beliefs about the need to control thoughts. These findings provide support for the significant role played by beliefs about control in predicting the severity of obsessive compulsive symptoms.

Cue Integration: A Common Framework for Social Cognition and Physical Perception

Scientists examining how people understand other minds have long thought that this task must be something like how people perceive the physical world. This comparison has proven to be deeply generative, as models of physical perception and social cognition have evolved in parallel. In this article, I propose extending this classic analogy in a new direction by proposing cue integration as a common feature of social cognition and physical perception. When encountering complex social cues-which happens often-perceivers use multiple processes for understanding others' minds. Like physical senses (e.g., vision or audition), social cognitive processes have often been studied as though they operate in relative isolation. In the domain of physical perception, this assumption has broken down, following evidence that perception is instead characterized by pervasive integration of multisensory information. Such integration is, in turn, elegantly described by Bayesian inferential models. By adopting a similar cue integration framework, researchers can similarly understand and formally model the ways that we perceive others' minds based on complex social information.

Psychometric Properties of a Short Korean Version of the Revised Obsessive Intrusion Inventory

OBJECTIVE

The Revised Obsessive Intrusion Inventory (ROII) is a 52-item scale that evaluates obsessional intrusive thoughts. The aim of the present study was to validate a short, 20-item Korean version of the ROII (ROII-20).

METHODS

Of the 1125 participants who completed the ROII-20, 895 participants completed the scale to examine the factor structure of the scale. A subgroup of these participants (n=53) completed the scale twice to determine test-retest reliability. To establish external validity, 230 participants completed the scale and other questionnaires.

RESULTS

Exploratory factor analyses suggested a hierarchical model comprising two higher order factors of autogenous obsessions (resulting from aggressive thoughts and sexual thoughts) and reactive obsessions (resulting from thoughts about contamination, thoughts about accidents, and thoughts about dirt). Confirmatory factor analyses supported this model. The results indicated good internal consistency and test-retest reliability. External validity was supported by relationships with obsessive-compulsive symptoms and general distress.

CONCLUSION

The ROII-20 presents good psychometric properties and may be considered as a promising instrument for measuring obsessional intrusions.

Fear of cancer recurrence in colorectal cancer survivors

Purpose

Although long-term colorectal cancer (CRC) survivors generally report a good quality of life, fear of cancer recurrence (FCR) remains an important issue. This study investigated whether the Cancer Worry Scale (CWS) can detect high FCR, the prevalence, and characteristics of FCR in CRC survivors.

Methods

Two hundred and eleven patients who had undergone successful CRC surgery in the period 2003–2010 in the Radboud University Medical Center in the Netherlands were asked to participate. All patients were sent an information letter plus questionnaires for collecting information on demographic and medical variables, FCR, distress, and quality of life.

Results

Seventy-six patients (36 %; median age of 67.7 years range 41–88 years) completed the questionnaires a median of 5.1 years after surgery. A cut-off score of 14 or higher on the CWS was optimal to detect high FCR. Twenty-nine patients (38 %) experienced high levels of FCR, characterized by higher levels of distress, post-traumatic stress symptoms, and lower quality of life. These individuals particularly reacted to disease-related triggers, felt helpless, were worried, and experienced limitations in daily functioning. High FCR was not associated with demographic or medical variables.

Conclusion

Long after successful CRC surgery, FCR is a serious problem that impairs the quality of life for a substantial proportion of patients. With the CWS, it is possible to detect high FCR and thereby assist survivors in receiving appropriate care.

Goal-directed learning and obsessive-compulsive disorder

Obsessive–compulsive disorder (OCD) has become a paradigmatic case of goal-directed dysfunction in psychiatry. In this article, we review the neurobiological evidence, historical and recent, that originally led to this supposition and continues to support a habit hypothesis of OCD. We will then discuss a number of recent studies that have directly tested this hypothesis, using behavioural experiments in patient populations. Based on this research evidence, which suggests that rather than goal-directed avoidance behaviours, compulsions in OCD may derive from manifestations of excessive habit formation, we present the details of a novel account of the functional relationship between these habits and the full symptom profile of the disorder. Borrowing from a cognitive dissonance framework, we propose that the irrational threat beliefs (obsessions) characteristic of OCD may be a consequence, rather than an instigator, of compulsive behaviour in these patients. This lays the foundation for a potential shift in both clinical and neuropsychological conceptualization of OCD and related disorders. This model may also prove relevant to other putative disorders of compulsivity, such as substance dependence, where the experience of ‘wanting’ drugs may be better understood as post hoc rationalizations of otherwise goal-insensitive, stimulus-driven behaviour.

‘Life just kind of sparkles’: clients’ experiences of being in cognitive behavioural group therapy and its impact on reducing shame in obsessive compulsive disorder

This study explored the personal accounts of service users relating to their experiences of being in group cognitive behavioural therapy (GCBT) for obsessive compulsive disorder (OCD). Eight participants were purposively selected from two groups whose therapy had finished. These participants were interviewed, the data transcribed verbatim and analysed using interpretative phenomenological analysis (IPA). Five superordinate themes were generated: ‘Engagement in the group process’, ‘Normalizing’, ‘Courage to fight’, ‘Being my own therapist’ and ‘Restricted vs. engagement with life’. The findings in this study have implications for theory in terms of the relevance of shame-based appraisals in conceptualizations of OCD. Suggestions for future groups include the importance of exploring the development of the problem in the group setting and highlight an important role for the group in terms of increasing motivation and preventing dropout. Directions for future research and implications for theory are explored.

Preliminary Evidence for the Enhancement of Self-Conducted Exposures for OCD using Cognitive Bias Modification

Exposure and Response Prevention (ERP) is the most effective treatment for OCD but it is not accessible to most patients. Attempts to increase the accessibility of ERP via self-directed ERP (sERP) programs such as computerized delivery and bibliotherapy have met with noncompliance, presumably because patients find the exposure exercises unacceptable. Previous research suggests that Cognitive Bias Modification (CBM) interventions may help individuals approach feared situations. The goal of the current study was to test the efficacy of a treatment program for OCD that integrates sERP with CBM. Twenty-two individuals meeting diagnostic criteria for OCD enrolled in our 7-week treatment program. Results suggest that sERP with CBM led to significant reduction of OCD symptoms and functional impairment. Indeed, the magnitude of the effect of this novel treatment, that requires only an initial session with a clinician trained in ERP for OCD, was comparable to that of the gold standard clinician-administered ERP. Moreover, preliminary evidence suggests that CBM interventions targeting interpretation bias may be most effective, whereas those targeting attention and working memory bias may not be so.

Food for thought: ego-dystonicity and fear of self in eating disorders

Degree of ego-dystonicity in obsessions is clinically relevant to the conceptualization and treatment of eating disorders (EDs). Obsessive-compulsive disorder research has suggested that the transformation of intrusive thoughts into obsessions is linked to the degree to which intrusive thoughts threaten core perceptions of the self. This study aims to explore the relationship between the ego-dystonic nature of obsessions in ED patients and a fear of self, the link between ED symptom severity and ego-dystonicity in obsessions, and differences between non-clinical and individuals with EDs in the presence of ego-dystonic thoughts and a fear of self. Ego-dystonicity (Ego-dystonicity Questionnaire (EDQ)) and feared self (Fear of Self Questionnaire (FSQ)) degrees were measured in a clinical sample (n = 57 with EDs) and a non-clinical sample (n = 45). EDQ and FSQ scores were highly correlated in both samples. EDQ scores were not significantly correlated to ED symptom severity with the exception of the EDQ Irrationality subscale, which was strongly related to compulsion severity. Participants with an ED had significantly higher EDQ and FSQ scores compared with controls.

Relationship between Obsessive Beliefs and Symptoms in Patients with Obsessive Compulsive Disorder

INTRODUCTION

Misinterpretation of intrusive thoughts because of obsessive beliefs has been thought to be important in the development of obsessive compulsive symptoms. In current study, (I) the difference between OCD patients and healthy controls in regard of obsessive beliefs and (II) the relation of obsesive beliefs with the prevelance and severity of obsessive compulsive symptoms was investigated.

METHODS

The current study included 47 OCD patients and 44 healthy controls who have same properties with regard to age, sex and duration of education. All subjects were applied to Obsessive Beliefs Scale, Maudsley Obsessive Compulsive Scale, Hamilton Depression Rating Scale and Hamilton Anxiety Rating Scale. OCD patients were applied to Yale Brown Obsessive Compulsive Scale as well as the other scales.

RESULTS

In analyses by controlling depression and anxiety scores, OCD patients had significantly higher scores than controls, with regard to all subscales of Obsessive Beliefs Scale. Also, prevalence of obsessive compulsive symptoms other than cleaning were correlated with obsessive beliefs about "responsibility and threat estimation" and "perfectionism and need for certainty". Hovewer, there was no correlation in between severity of obsessive compulsive symptoms and subscale scores of Obsessive Beliefs Scale.

CONCLUSION

Excluding the effects of depression and anxiety, generally the results suggests that obsessive beliefs have an important role for development of obsessive compulsive symptoms. Future studies of seperated OCD subgroup with regard to obsessive compulsive symptoms will be helpful in determinig the difference among these subgroups in regard of obsessive beliefs.

Self-Based Concepts and Obsessive-Compulsive Phenomena

BACKGROUND/AIMS

Using a cognitive framework, this paper examined self-perceptions as a vulnerability to phenomena in obsessive-compulsive disorder. Specifically, Guidano and Liotti's model of self-ambivalence (from 1983) and the notion of self-worth contingent upon moral standards were investigated as possible mechanisms to explain how individuals come to notice their unwanted intrusions.

METHOD

Using an analogue framework, participants were first-year undergraduate psychology students (95 females, mean age = 22.49 years, SD = 7.96, and 25 males, mean age = 21.64 years, SD = 7.26) who were administered a battery of self-report questionnaires.

RESULTS

Results indicated that self-ambivalence moderated the relationship between high moral standards and obsessive-compulsive (OC) phenomena; individuals who had high moral standards and high self-ambivalence showed increased OC vulnerability.

CONCLUSIONS

The findings suggest that ambivalence about moral self-worth may constitute a particular vulnerability to OC symptoms. Directions for future research are discussed and implications of the findings explored.