Schizotypal, Dissociative, and Imaginative Processes in a Clinical OCD Sample

The relevance of dysfunctional reasoning to OCD and its treatment: Further evidence for inferential confusion utilizing a new task-based measure

BACKGROUND AND OBJECTIVES

Previous research has highlighted the role of dysfunctional reasoning processes (i.e. "inferential confusion") in the development and maintenance of Obsessive-Compulsive Disorder (OCD). Inferential confusion has previously been found to be a unique predictor of OC symptoms and has shown specificity for OCD. However, these findings have primarily relied on a single self-report questionnaire, and only a limited number of experimentations have been conducted to establish the specificity of inferential confusion to OCD with alternate measures. The current paper demonstrates the relationship of inferential confusion with OCD symptoms in clinical samples by using a task-based measure of inferential confusion.

METHODS

Sixty-four OCD participants, as well as thirty anxious and thirty-four healthy controls completed the recently developed Dysfunctional Reasoning Processes Task (DRPT) and related measures. Thirty-five OCD participants then completed sixteen sessions of cognitive-behavioural therapy (CBT) and completed the same measures post-treatment.

RESULTS

As predicted, dysfunctional reasoning was significantly more elevated for those with OCD relative to control groups. Reduced levels of dysfunctional reasoning during CBT were significantly associated with successful treatment outcome.

LIMITATIONS

Clinical implications should be interpreted with caution due to the relatively small sample size.

CONCLUSIONS

Our findings support the notion that inferential confusion is an important cognitive factor particularly relevant to OCD that needs to be directly addressed as a mechanism of change in CBT.

Obsessive-compulsive symptoms and dissociative experiences: Suggested underlying mechanisms and implications for science and practice

A strong and specific link between obsessive-compulsive disorder or symptoms (OCD/S) and a tendency for dissociative experiences (e.g., depersonalization-derealization, absorption and imaginative involvement) cannot be explained by trauma and is poorly understood. The present theoretical formulation proposes five different models conceptualizing the relationship. According to Model 1, dissociative experiences result from OCD/S through inward-focused attention and repetition. According to Model 2, dissociative absorption causally brings about both OCD/S and associated cognitive risk factors, such as thought-action fusion, partly through impoverished sense of agency. The remaining models highlight common underlying causal mechanisms: temporo-parietal abnormalities impairing embodiment and sensory integration (Model 3); sleep alterations causing sleepiness and dreamlike thought or mixed sleep-wake states (Model 4); and a hyperactive, intrusive imagery system with a tendency for pictorial thinking (Model 5). The latter model relates to Maladaptive Daydreaming, a suggested dissociative syndrome with strong ties to the obsessive-compulsive spectrum. These five models point to potential directions for future research, as these theoretical accounts may aid the two fields in interacting with each other, to the benefit of both. Finally, several dissociation-informed paths for further developing clinical intervention in OCD are identified.

Schizotypal personality disorder in clinical obsessive-compulsive disorder samples: a brief overview

Obsessive-compulsive disorder (OCD) is a chronic and disabling mental disorder characterized by the presence of obsessions and/or compulsions that cause major distress and impair important areas of functioning. About 9 out of 10 patients with OCD have comorbid psychiatric diagnoses. A high proportion of clinically diagnosed OCD patients fulfill diagnostic criteria of a schizophrenia spectrum disorder, to the point that significant evidence in the literature supports the existence and the clinical relevance of a schizo-obsessive spectrum of disorders, including schizotypal personality disorder (SPD) with OCD (schizotypal OCD). In this paper, we provide a brief but comprehensive analysis of the literature on the clinical coexistence between OCD and SPD. The clinical validity of the so-called schizotypal OCD is analyzed through a comprehensive investigation of the relationship between SPD features and obsessive-compulsive phenomena in clinical OCD samples. This review describes the potential connections between OCD and SPD on the epidemiological, sociodemographic, psychopathological, and clinical levels. SPD is commonly observed in OCD patients: about 10% of OCD patients have a full categorical diagnosis of SPD. Early clinical identification of SPD features-and, more generally, of psychotic features and personality disorders-in OCD patients is strongly recommended. In fact, a proper and early diagnosis with early treatment may have benefits for prognosis. However, although schizotypal OCD seems to have clinical and predictive validity, further neurobiological and genetic studies on etiological specificity are warranted.

From brooding to detachment: Rumination longitudinally predicts an increase in depersonalization and derealisation

OBJECTIVES

Depersonalization-derealization (DEP-DER) is a dissociative experience which is related to psychopathology and distress. Yet, the aetiological factors leading to DEP-DER are not sufficiently clear. In this study, we suggest rumination as one possible antecedent. Thus, the goal of the study was to explore the longitudinal relationship between rumination and DEP-DER.

DESIGN

Longitudinal self-report study; mixed clinical and community sample.

METHODS

The study was conducted on 98 participants, 49 of them were diagnosed with depression, anxiety disorders, or obsessive-compulsive disorder, and the other 49 were healthy, matched community controls. The participants underwent a structured clinical interview and completed a battery of questionnaires. Then, the participants completed the same battery again once a month, for five additional assessment points (6 months in total). The data were analysed using multilevel linear modelling with time-lag analysis.

RESULTS

We found that levels of rumination and DEP-DER increased and decreased simultaneously, meaning that on assessments in which people reported that they tended to ruminate, they also reported higher levels of DEP-DER symptoms. In addition, we found support for a unidirectional association, consistent with our theoretical hypothesis. Specifically, rumination levels on a certain month longitudinally predicted a higher likeliness for reporting DEP-DER on the following month, even when controlling for the contemporaneous relationship. Conversely, DEP-DER symptoms did not longitudinally predict increased rumination.

CONCLUSIONS

These findings suggest that rumination may be an antecedent of DEP-DER, but not vice versa. Possible mechanisms to explain this link are discussed.

PRACTITIONER POINTS

Rumination and DEP-DER oscillate together over time; additionally, rumination predicts a longitudinal increase in DEP-DER. Clinicians noticing ruminative thought followed by decreased emotionality should distinguish between an authentic decrease of distress versus detachment. The findings provide one possible explanation for the frequency of DEP-DER symptoms in anxiety and depressive disorders. Poor sleep quality and emotion regulation difficulties should be explored as potential mediators explaining this link.

Reality check: An experimental manipulation of inferential confusion in eating disorders

BACKGROUND AND OBJECTIVES

Inferential confusion (IC) entails confusing an imagined possibility with a sensory-based possibility, and acting upon the imagined possibility as if it was real. Although IC was formulated in the context of obsessive-compulsive disorder (OCD), this reasoning bias has shown to be relevant to other obsessive-compulsive spectrum disorders, such as eating disorders (EDs). The goal of this study was to induce IC experimentally in individuals with EDs relative to healthy controls (HC).

METHODS

Thirty-six women (ED group, n = 18; HC group, n = 18) were assigned to one of two experimental conditions: in the High IC condition, participants watched ED-themed videos with key sequences missing - provoking a distrust of the senses and lending more space for the imagination, thus triggering IC. In the Low IC condition, participants watched videos without sequences missing. Participants completed measures of IC, negative affect and compulsive behaviors after watching the videos.

RESULTS

One-way ANOVA indicated that ED participants assigned to the High IC condition reported a greater urge to engage in compulsive behaviors. ED participants also neutralized more after watching the videos and endorsed higher trait IC.

LIMITATIONS

There was no clinical control group.

CONCLUSIONS

These findings suggest that individuals with EDs display a greater vulnerability to IC, as they are more prone to compulsive behaviors when IC is triggered. This investigation may foster our understanding of the relationship between EDs and OCD through the examination of cognitive factors that are implicated in both disorders.

Personality traits in adults with hoarding disorder

BACKGROUND

Prior research has demonstrated a link between compulsive hoarding symptoms and personality traits; however, no studies have investigated the link between hoarding and personality traits utilizing a sample of individuals diagnosed with hoarding disorder (HD) using formal diagnostic criteria. The aim of the current study was to evaluate the frequency and type of personality traits in adults diagnosed with HD and to explore the associations among hoarding severity and personality disorder traits within this sample.

METHODS

Seventy-two veterans enrolled in an ongoing treatment trial for HD completed a battery of self-report measures during their initial assessment. Linear regression analyses were used to determine the unique variance accounted for by hoarding severity in predicting scores on the personality disorder scales from the Millon Clinical Multiaxial Inventory-III (MCMI-III).

RESULTS

The majority of participants had an elevated score on at least one of the MCMI-III Personality scales. The most frequently elevated scores were for the Avoidant, Dependent, Depressive, and Schizoid scales. Hoarding severity was a significant predictor of personality traits in 10 out of 14 MCMI-III scales.

LIMITATIONS

Given the exploratory nature of the investigation, we did not control for multiple comparisons or the presence of mood or anxiety disorders.

CONCLUSIONS

The elevated prevalence of co-occurring personality pathology in adults with HD indicates the importance of considering underlying personality structure when developing individualized treatment plans.

Further Examining the Construct Validity of the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) Personality Disorder Spectra Scales

The Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) Personality Disorder (PD) Spectra scales reflect a recent effort to dimensionally measure Diagnostic and Statistical Manual of Mental Disorders-5-based personality disorders. Initial studies generally support the sound psychometric properties of most scales, although the need to continue cross-validating and expanding the known empirical correlates of these scales remains. The goal of the current investigation was to replicate and extend previous research on MMPI-2-RF PD Spectra scale scores and further examine their construct validity. Using a sample of 765 undergraduate students (69.3% female; M_age = 19.95; 73.3% White), zero-order correlations between scores on MMPI-2-RF PD Spectra scales and measures of personality and psychopathology variables were calculated. Median convergent and discriminant correlations were compared using Fisher's r-to-z tests. Results indicated that hypothesized convergent associations were meaningfully stronger in magnitude than hypothesized discriminant ones, with exceptions to scales measuring Obsessive-Compulsive, Narcissistic, and Paranoid PDs. Findings generally supported the construct validity of MMPI-2-RF PD Spectra scale scores. Implications for clinical practice and research, methodological limitations, and suggestions for future research are discussed.

Association Between Alexithymia and Immature Coping Styles Is Mediated by Self-Inconsistency and Is Correlated to Obsessive-Compulsive Symptoms

This study aimed to investigate whether a multivariate association between alexithymia and coping styles is affected by self-inconsistency and whether the association contributed to obsessive-compulsive symptoms in 34 patients with obsessive-compulsive disorder (OCD) and 53 healthy participants. Alexithymia, coping styles, self-inconsistency, and obsessive-compulsive symptoms were evaluated using the Toronto Alexithymia Scale-20, the Coping Style Questionnaire, the Self-Consistency and Congruence Scale, and the Vancouver Obsessive-Compulsive Inventory, respectively. We found that self-inconsistency partially mediated the association between alexithymia and immature coping styles in the OCD patients but fully mediated the association in the healthy participants. Moreover, in the two groups, the alexithymia-coping coupling was related to contamination, obsession, indecisiveness, and ritualization, but not the checking symptom dimension. The findings suggest that the disturbance in identifying and describing feelings is associated with immature coping styles through disharmony between self-recognition and experience. The mechanism of the checking symptom seems to be distinct from other obsessive-compulsive symptoms.

Differences in obsessive-compulsive symptom dimensions between patients with epilepsy with obsessive-compulsive symptoms and patients with OCD

Clinical correlates of obsessive-compulsive symptoms (OCS) were evaluated in 100 adult consecutive outpatients with epilepsy, using the Obsessive-Compulsive Inventory (OCI-R), Beck Depression Inventory (BDI), Dissociative Experiences Scale (DES-II), and the Schizotypal Personality Questionnaire (SPQ). Dimensional Yale-Brown Obsessive-Compulsive Scale (DY-BOCS) was applied to determine the types and severity of OCS to the 45 patients with epilepsy who were over 21 points on the OCI-R scale and 30 patients who were with diagnosed obsessive-compulsive disorder (OCD) among the patients in the psychiatry outpatient clinic, as a control group. As a result, it was found that patients with epilepsy with OCS tend to have more symmetry/exactness obsessions and compulsions, whereas patients with OCD had significantly more contamination/cleaning and aggressiveness obsessions and compulsions. In addition, OCS was found to be significantly higher in temporal lobe epilepsy (TLE) and extratemporal epilepsy than generalized epilepsy. However, OCS were correlated with depression, dissociation, and schizotypy in patients with epilepsy, while only depression was predictive when regression analysis was performed for OCS. This study is the first study to compare patients with OCD with patients with epilepsy in terms of the nature of OCS and first identified the differences in OCS dimensions between patients with epilepsy with OCS and patients with OCD.

Inverse reasoning processes in obsessive-compulsive disorder: Replication in a clinical sample

The inference-based approach (IBA) is one cognitive model that aims to explain the aetiology and maintenance of obsessive-compulsive disorder (OCD). IBA theory suggests that certain reasoning processes lead an individual with OCD to confuse imagined possibilities with actual probabilities, a process termed inferential confusion. One such reasoning process is inverse reasoning, where hypothetical causes form the basis of conclusions about reality. Recently, we developed a task-based measure of inverse reasoning. In an online sample, we reported significant and positive associations between endorsement of inverse reasoning on this task and OCD symptomatology. We concluded that there was some support for the role of inverse reasoning in OCD but these results required extension using a between-groups design in a clinical sample. Therefore, the present study compared endorsement in inverse reasoning on this task between individuals diagnosed with OCD, anxiety and/or mood disorder (clinical controls), and healthy individuals (healthy controls). Relative to both control groups, the OCD group demonstrated significantly greater endorsement in inverse reasoning on scenarios where OCD relevant concerns were prompted. When non-OCD relevant concerns were involved, the OCD group only evidenced greater endorsement in inverse reasoning relative to the healthy control group. Implications for IBA theory are discussed.

No Time Like the Present: Thinking About the Past and the Future Is Related to State Dissociation Among Individuals With High Levels of Psychopathological Symptoms

Several short-term pathways have been implicated in relation to dissociative experiences, among them are daily stress, sleepiness, and rumination. In addition, it has been claimed that mechanisms contributing to dissociative experiences may differ, according to specific psychopathological symptoms. Accordingly, this study had two aims. The first was to sample moment-to-moment increases or decreases in current stress, sleepiness, and rumination, in order to assess their temporal relations with state dissociation. Rumination was broken down to its basic two subcomponents: the negative value of the thoughts and thinking about the past (in comparison to present or future), in order to differentiate it from other repetitive thought patterns (e.g., worry). The second goal was to explore whether depression, anxiety, and obsessive–compulsive symptoms may moderate the links between the three mechanisms and specific state dissociation scales [specifically, depersonalization-derealization (DEP-DER) and absorption (ABS)]. Ninety-nine undergraduate students completed trait questionnaires and then answered state items four times a day for 4 days. These experience sampling data were analyzed using multilevel linear modeling (MLM) with Level 1 state measurements and Level 2 demographic and trait variables of the participants. Moments of stress, sleepiness, thinking about the past and negative thoughts were all associated both with state DEP-DER and with state ABS. Dissociation, negative thinking, stress, and sleepiness were positively associated with moments of thinking about the past and the future but inversely associated with moments of thinking about the present. Finally, in accordance with our expectations, the links between DEP-DER and hypothesized mechanisms were mostly moderated by depression and anxiety symptoms, whereas the links between ABS and hypothesized mechanisms were moderated mainly by obsessive–compulsive symptoms. Our findings are in accordance with literature on the efficacy of mindfulness as well as the maladaptive correlates of mind-wandering, as they suggest that dissociative detachment from one’s present occupation is associated with decreased well-being.

Development and Preliminary Psychometric Properties of an Instrument for the Measurement of Obsessional Dissociative Experiences: The Van Obsessional Dissociation Questionnaire (VOD-Q)

A growing body of research evidence documents the substantial associations between obsessive-compulsive disorder (OCD) and dissociation. This article describes the development and preliminary psychometric properties of the Van Obsessional Dissociation Questionnaire (VOD-Q). Obsessional dissociation is defined as a tendency to dissociate in reaction to distressing, unwanted and intrusive thoughts, images and impulses. The screening tool is conceptualized to tap obsessional dissociation across three dimensions: obsessional absorption, obsessional depersonalization/ derealization and obsessional amnesia. The VOD-Q, the Padua Inventory-Revised (PI-R), the Dissociative Experiences Scale (DES), and the Obsessive Belief Questionnaire (OBQ-44) were administered in this study. The results showed that the VOD-Q had excellent test-retest reliability (ranging from 0.73 to 0.90) and internal consistency (ranging from 0.90 to 0.97). The VOD-Q total and subscale scores were significantly associated with measures of obsessive-compulsive symptoms and dissociative experiences. OCD patients scored significantly higher on the VOD-Q than community participants. Based on the present findings, the VOD-Q appears to be a reliable and valid instrument for the measurement of obsessional dissociative experiences.

Neurological soft signs, dissociation and alexithymia in patients with obsessive-compulsive disorder (OCD) and healthy subjects

A body of evidence has supported that patients with obsessive-compulsive disorder (OCD) have increased rates of various neurological soft signs (NSS) compared to controls. Various lines of research has documented robust relationships between OCD and dissociative symptomatology. The study aimed to examine the associations between obsessive-compulsive symptoms, dissociative experiences alexithymia, and NSS. The study included thirty OCD patients and thirty healthy controls, matched for age, marital status, education, and income. The Neurological Evaluation Scale (NES), Padua Inventory-Revised (PI-R), Dissociative Experiences Scale (DES) and Toronto Alexithymia Scale (TAS-20) were administered. In comparison to healthy controls, patients with OCD had difficulty sequencing for complex motor acts and greater absorption/ imaginative involvement. Using latent class analysis, the study sample was classified into two homogenous subsets as mild NSS (n = 45) and severe NSS (n = 15). Majority of the participants who were grouped into severe NSS latent class were OCD patient (n = 14, 93.3%). Furthermore, those with severe NSS reported greater levels of alexithymia and more severe obsessive-compulsive symptoms, particularly precision. We concluded that relationships between OCD severity and NSS appear to be of crucial importance. Our data along with accumulated evidence suggest that OCD associated with pronounced NSS may represent a specific subtype of the disorder.

Trapped in a Daydream: Daily Elevations in Maladaptive Daydreaming Are Associated With Daily Psychopathological Symptoms

Background: Maladaptive Daydreaming (MD) characterizes individuals who engage in vivid, fanciful daydreaming for hours on end, neglecting real-life relationships and responsibilities, resulting in clinical distress and functional impairment. Sufferers have embraced the term MD in cyber-communities devoted to this problem because it seemed to uniquely fit their experience and since existing diagnostic labels and their therapies seemed inadequate. However, scientific research in the field has been scarce, relying on cross-sectional or case study designs. Existing knowledge on MD suggests the involvement of dissociative and obsessive-compulsive symptoms, as well as positive reinforcement comparable to processes in addiction disorders. The present study aimed to rigorously explore factors that accompany MD employing a longitudinal daily-diary design, hypothesizing that temporal increases in MD will associate concurrently with, and will temporally precede, other symptoms and emotional changes. In addition, we aimed to explore which symptoms may act as precursors to increases in MD, in order to identify possible mechanisms bringing about daydreaming in these individuals. Methods: In a sample of 77 self-diagnosed individuals with MD we assessed relevant daily symptoms for 14 days, including MD, depression, general anxiety, social anxiety, obsessive-compulsive symptoms, and dissociation, as well as positive and negative emotion. Results: Increases in MD were strongly related to concurrent increases in all other symptoms and negative emotion, and to decreased positive emotion. Obsessive-compulsive symptoms, dissociation, and negative emotion also temporally followed MD. Obsessive-compulsive symptoms were the only consistent temporal antecedent of MD. Conclusions: MD and obsessive-compulsive symptoms coincided in what seems to be a vicious cycle; understanding possible shared mechanisms between these symptoms may inform our understanding of the etiology of MD. For example, Serotonin levels may possibly be involved in the development or maintenance of this condition. The findings may also provide clues as to potentially beneficial interventions for treating MD. For example, perhaps utilizing response prevention techniques may be useful for curbing or intercepting unwanted daydreaming. Future studies on MD should address its compulsory nature.

Causal role for inverse reasoning on obsessive-compulsive symptoms: Preliminary evidence from a cognitive bias modification for interpretation bias study

BACKGROUND AND OBJECTIVES

The inference-based approach (IBA) is a cognitive account of the genesis and maintenance of obsessive-compulsive disorder (OCD). According to the IBA, individuals with OCD are prone to using inverse reasoning, in which hypothetical causes form the basis of conclusions about reality. Several studies have provided preliminary support for an association between features of the IBA and OCD symptoms. However, there are currently no studies that have investigated the proposed causal relationship of inverse reasoning in OCD.

METHODS

In a non-clinical sample (N = 187), we used an interpretive cognitive bias procedure to train a bias towards using inverse reasoning (n = 64), healthy sensory-based reasoning (n = 65), or a control condition (n = 58). Participants were randomly allocated to these training conditions. This manipulation allowed us to assess whether, consistent with the IBA, inverse reasoning training increased compulsive-like behaviours and self-reported OCD symptoms.

RESULTS

Results indicated that compared to a control condition, participants trained in inverse reasoning reported more OCD symptoms and were more avoidant of potentially contaminated objects. Moreover, change in inverse reasoning bias was a small but significant mediator of the relationship between training condition and behavioural avoidance. Conversely, training in a healthy (non-inverse) reasoning style did not have any effect on symptoms or behaviour relative to the control condition.

LIMITATIONS

As this study was conducted in a non-clinical sample, we were unable to generalise our findings to a clinical population.

CONCLUSIONS

Findings generally support the IBA model by providing preliminary evidence of a causal role for inverse reasoning in OCD.

The inference-based approach to obsessive-compulsive disorder: A comprehensive review of its etiological model, treatment efficacy, and model of change

BACKGROUND

The inference-based approach (IBA) postulates that individuals with obsessive-compulsive disorder (OCD) confuse a possibility with reality (inferential confusion) according to specific inductive reasoning devices and act as if this possibility were true. A new treatment modality, the inference-based therapy (IBT), was developed. The aim of this study was to critically review empirical evidence regarding the etiological model, treatment efficacy, and model of change of IBA.

METHODS

A search of the literature was conducted using PsycINFO and Medline.

RESULTS

Thirty-four articles were included in the review. The review reveals that intrusive thoughts of non-clinical and OCD individuals may occur in different contexts. There is support for a specific inductive reasoning style in OCD. Inferential confusion is associated with OCD symptoms. There is good evidence that IBT is an efficacious treatment for OCD, including two randomized controlled trials showing that IBT was as efficacious as cognitive-behavior therapy. There is some but limited evidence that the process of change during treatment is coherent with IBA's assumptions.

LIMITATIONS

Key premises were investigated in only a few studies. Some of these studies were conducted in non-clinical samples or did not include an anxious control group.

CONCLUSIONS

IBA's etiological model, treatment modality, and model of change make a significant contribution to OCD.

Perseveration induces dissociative uncertainty in obsessive-compulsive disorder

BACKGROUND AND OBJECTIVES

Obsessive compulsive (OC)-like perseveration paradoxically increases feelings of uncertainty. We studied whether the underlying mechanism between perseveration and uncertainty is a reduced accessibility of meaning ('semantic satiation').

METHODS

OCD patients (n = 24) and matched non-clinical controls (n = 24) repeated words 2 (non-perseveration) or 20 times (perseveration). They decided whether this word was related to another target word. Speed of relatedness judgments and feelings of dissociative uncertainty were measured. The effects of real-life perseveration on dissociative uncertainty were tested in a smaller subsample of the OCD group (n = 9).

RESULTS

Speed of relatedness judgments was not affected by perseveration. However, both groups reported more dissociative uncertainty after perseveration compared to non-perseveration, which was higher in OCD patients. Patients reported more dissociative uncertainty after 'clinical' perseveration compared to non-perseveration..

LIMITATIONS

Both parts of this study are limited by some methodological issues and a small sample size.

CONCLUSIONS

Although the mechanism behind 'perseveration → uncertainty' is still unclear, results suggest that the effects of perseveration are counterproductive.