Assessing Sexually Intrusive Thoughts: Parsing Unacceptable Thoughts on the Dimensional Obsessive-Compulsive Scale

Rethinking Unacceptable Thoughts: Validation of an Expanded Version of the Dimensional Obsessive-Compulsive Scale

The Dimensional Obsessive-Compulsive Scale (DOCS) is widely used to measure obsessive-compulsive disorder (OCD) severity across four broad symptom dimensions (i.e., contamination, responsibility for harm, unacceptable thoughts, symmetry). Despite its proven utility, there is reason to suspect that the unacceptable thoughts subscale conflates different types of unacceptable thoughts that are meaningfully distinct from one another. In the current study, we first evaluated the psychometric properties of a newly developed DOCS violent and/or aggressive thoughts subscale. We then examined the factor structure, psychometric properties, and diagnostic sensitivity of a seven-factor version of the DOCS that includes the four original DOCS subscales and three more-specific versions of the unacceptable thoughts scale (i.e., sexually intrusive thoughts, violent and/or aggressive thoughts, and scrupulous or religious thoughts). The sample included 329 residential and intensive outpatients, the majority of which had a diagnosis of OCD (75.2%). The new unacceptable thoughts subscales demonstrated convergent and discriminant validity with unique associations between the subscales and depression, suicide, and perceived threat from emotions that were not present in the broader unacceptable thoughts subscale. The seven-factor version of the DOCS demonstrated slightly lower levels of diagnostic sensitivity than the original DOCS. Thus, the four-factor version of the DOCS is recommended for screening purposes. A score of 40 or higher on the seven-factor version of the DOCS best predicted a diagnosis of OCD. Overall, the three additional unacceptable thoughts subscales appear to be distinct factors that have potential value in research and clinical settings.

Sexual Orientation Intrusive Thoughts and Well-Being: The Mediating Role of Psychological Inflexibility

Sexual orientation intrusive thoughts are a debilitating form of obsessive-compulsive disorder. The present study aimed to elucidate how psychological inflexibility and dysfunctional beliefs may impact the relationships of sexual orientation intrusive thoughts and obsessive-compulsive (OC) symptoms with well-being. A total of 181 undergraduate students completed measures of sexual orientation intrusive thoughts, OC symptoms, psychological inflexibility, dysfunctional beliefs, and well-being. Results indicated positive correlations between psychological inflexibility, sexual orientation intrusive thoughts, dysfunctional beliefs, and OC symptoms, along with negative correlations between well-being and sexual orientation intrusive thoughts, OC symptoms, dysfunctional beliefs, and psychological inflexibility. Psychological inflexibility acted as a mediator between sexual orientation intrusive thoughts and well-being and between OC symptoms and well-being. Dysfunctional beliefs were not a significant mediator. These results suggest that psychological inflexibility may partially explain the association between OC symptoms and well-being, pointing toward the need for future research on the impact of psychological inflexibility on well-being in the context of OC symptoms.

Best practices for CBT treatment of taboo and unacceptable thoughts in OCD

Although general cognitive behavioural therapy (CBT) can help alleviate distress associated with obsessive-compulsive disorder (OCD), strategies tailored to targeting specific cognitions, feelings, and behaviours associated with OCD such as exposure and ritual prevention (Ex/RP) and cognitive therapy (CT) have been shown to be a significantly more effective form of treatment. Treatment of individuals with unacceptable/taboo obsessions requires its own specific guidelines due to the stigmatizing and often misunderstood nature of accompanying thoughts and behaviours. In this article, OCD expert practitioners describe best practices surrounding two of the longest standing evidence-based treatment paradigms for OCD, CT and Ex/RP, tailored specifically to unacceptable and taboo obsessions, so that clients may experience the best possible outcomes that are sustained once treatment ends. In addition, CT specifically targets obsessions while Ex/RP addresses compulsions, allowing the two to be highly effective when combined together. A wide range of clinical recommendations on clinical competencies is offered, including essential knowledge, psychoeducation, designing fear hierarchies and exposures, instructing the client through behavioural experiments, and relapse prevention skills.

Key learning aims

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A New Scrupulosity Scale for the Dimensional Obsessive-Compulsive Scale (DOCS): Validation With Clinical and Nonclinical Samples

Scrupulous obsessions are a prominent presentation of obsessive-compulsive disorder (OCD). Previous conceptualizations of scrupulosity have indicated that it belongs to the unacceptable thoughts dimension, which pertains to sexual, violent, and religious obsessive themes. However, research suggests that scrupulous symptoms may differ from other unacceptable thoughts symptoms, necessitating the need for targeted and thorough assessment. We added a Scrupulous or Religious Thoughts subscale (DOCS-SR) to the Dimensional Obsessive-Compulsive Scale (DOCS) and tested its factorial structure, psychometric properties, and clinical correlates in a nonclinical and clinical sample. In the first study, nonclinical participants (N = 203) completed the DOCS-SR, which was subjected to an exploratory factor analysis. Analyses revealed that the DOCS-SR reflected a one-factor solution and possessed acceptable internal consistency, as well as strong convergent validity with clinical correlates of OCD. In the second study, we administered the DOCS, as well as the DOCS-SR to a clinical sample (N = 314). An exploratory factor analysis and confirmatory factor analysis both suggested that the four subscales and additional DOCS-SR represented a five-factor solution. Internal consistency and convergent validity were strong. The DOCS Unacceptable Thoughts subscale and the DOCS-SR shared a moderate correlation but evidenced differences in associations with other correlates. This suggested both convergent and divergent validity. Collectively, our results support the utility of examining the individual components of the unacceptable thoughts dimension of OCD for effective assessment and treatment planning.

Electroconvulsive Therapy in Refractory Obsessive-Compulsive Disorder: A Case Report

ABSTRACT

Electroconvulsive therapy (ECT) is a treatment of undisputed efficacy for severe and treatment-resistant psychiatric disorders. Notwithstanding extensive data on efficacy and safety, it is significantly underused, corresponding to one of the most stigmatized approaches in psychiatry. The list of problems for which ECT is potentially effective does not include obsessive-compulsive disorder (OCD), resulting in only a few available case reports in the literature in which OCD is the target of this specific therapeutic strategy. The authors describe a patient with refractory OCD for whom ECT was prescribed, with remarkable clinical response and functional improvement. The existence of a clear response to ECT in reported cases of OCD, albeit in a globally small number of patients, should make it essential to identify predictors of ECT response that could assist clinicians in assessing and guiding such cases, particularly those labeled as refractory to treatment.

Sexual Trauma, Cognitive Appraisals, and Sexual Intrusive Thoughts and Their Subtypes: A Moderated Mediation Analysis

The relationships between sexual trauma, cognitive appraisals, and subtypes of sexual intrusive thoughts have not been adequately examined in the context of obsessive-compulsive concerns. We employed variations of a moderated mediation model to test these relationships, situating sexual trauma as the predictor, sexual intrusive thoughts as the outcome, cognitive appraisals of these thoughts as the mediator, and subtypes of sexual intrusive thoughts as the moderator of the predictor-mediator link. Based on the continuum perspective, 180 individuals (159 females, 21 males) with or without a history of sexual trauma were recruited to complete measures assessing their most distressing sexual intrusion, cognitive appraisals, and severity of sexual intrusive thoughts. The results indicated that individuals with a history of sexual trauma reported more intrusions with sexual harm content, greater distress with sexual intrusions, more dysfunctional appraisals, and more severe sexual intrusions. The trauma-sexual intrusions link was also separately mediated by responsibility and importance/control appraisals (and when combined), with medium-to-large effect sizes, although this model was not moderated by whether intrusions contained sexual harm content or not. These findings shed light on the posttraumatic effects of sexual violence on sexual intrusions, their appraisals, and level of distress and functional impairment associated with sexual intrusive thoughts, with key clinical and research implications.

Association Splitting for Obsessive-Compulsive Disorder: A Systematic Review

Background:

Association splitting is a cognitive technique that targets obsessions in obsessive-compulsive disorder (OCD) by weakening biased semantic associations among OCDrelevant concepts.

Objective:

In this systematic review, we examine studies on the efficacy of association splitting for reducing OCD symptoms.

Methods:

Following PRISMA guidelines, six studies were included, with diversity in sample characteristics, mode of administration (i.e., self-help vs therapist-assisted), language of administration, comparator groups, etc.

Results:

Results indicated that association splitting, as a self-help intervention, was efficacious in reducing overall OCD symptom severity, specific OCD symptoms (i.e., sexual obsessions), subclinical unwanted intrusions, and thought suppression, with small-to-large effect sizes (e.g., across relevant studies, ds = .28-1.07). Findings were less clear when association splitting was administered on a therapist-assisted basis as an add-on to standard cognitive-behavior therapy (CBT). Nonetheless, across studies, the majority of participants reported high acceptability, ease of comprehension, and adherence to daily association splitting practice.

Conclusion:

Although association splitting is an efficacious and acceptable self-help intervention for OCD symptoms, future studies should include appropriate comparison groups, conduct longitudinal assessments, examine efficacy for different symptom dimensions, and assess changes in semantic networks as proof of mechanistic change. There should also be greater representation of marginalized groups in future studies to assess association splitting’s utility in circumventing barriers to face-to-face CBT. Ethical considerations are also discussed.

Assessing Sexual Orientation Symptoms in Obsessive-Compulsive Disorder: Development and Validation of the Sexual Orientation Obsessions and Reactions Test (SORT)

Obsessive-compulsive disorder (OCD) includes many symptom presentations, which creates unique diagnostic challenges. Fears surrounding one's sexual orientation are common within OCD (also called SO-OCD), but SO-OCD is consistently misdiagnosed by physicians and psychologists. To address this issue, we describe the development of a self-report measure for assessing SO-OCD to help distinguish OCD from distress caused by a sexual orientation identity crisis. The current paper details two studies that established the psychometric properties and clinical utility of this measure. In Study 1, the factor structure, validity, and reliability were examined for the measure's 12 items in a sample of 1,673 university students. The results revealed a two-factor solution for the measure (Factor 1: Transformation Fears; Factor 2: Somatic Checking) and preliminary evidence of validity and reliability. In Study 2, the measure was tested with LGBTQ and heterosexual community samples and clinical samples of individuals with SO-OCD and other types of OCD. The two-factor solution and evidence of validity and reliability were supported in these samples. Cut-off points were established to distinguish between community members and SO-OCD sufferers, as well as between those experiencing SO-OCD and other types of OCD. Limitations and future directions are discussed.

Can Distressing Sexual Thoughts Be Regulated? Experiential Willingness Versus Distraction

This study examines the effects of different techniques on the management of unwanted sexual thoughts. Participants (N = 150; 67 who found sexual thoughts distressing, 83 participants who did not) were randomly placed into one of three experimental conditions: experiential willingness, distraction, or no strategies for dealing with unwanted sexual thoughts. Participants answered questions assessing attitudes about their sexual thoughts and recorded sexual thought frequency for a 3-minute period pre- and post-intervention. Thought frequencies decreased for all groups post intervention for both the distressed and nondistressed samples. Acceptability of thoughts increased for the experiential willingness group, remained similar for the distraction group, and decreased for the control group. The findings indicate that distraction was more easily implemented, more commonly used, and equally effective to experiential willingness at reducing sexual thoughts in the short term. However, the short experiential willingness intervention increased acceptability of sexual thoughts, which could have an impact on longer-term results.

Pedophilia-Themed Obsessive-Compulsive Disorder: Assessment, Differential Diagnosis, and Treatment with Exposure and Response Prevention

Fears of sexually harming children are fairly common among clients suffering from obsessive-compulsive disorder (OCD), yet these symptoms are largely unrecognized and frequently misdiagnosed by mental health professionals. Specifically, clients with pedophilia-themed OCD (P-OCD) experience excessive worries and distressing intrusive thoughts about being sexually attracted to, and sexually violating, children. Expressing these concerns may provoke misjudgments from uninformed mental health professionals that a client is presenting instead with pedophilic disorder. This misdiagnosis and subsequent improper interventions can then contribute to increased fear, anxiety, and in many cases, depression, in affected clients. Therefore, it is imperative that mental health professionals first possess a good understanding of this common manifestation of OCD. As such, in this article, we described obsessions and compulsions typical of P-OCD, in order to inform the reader of the distinctive differences between P-OCD and pedophilic disorder. Information about how to assess for P-OCD symptoms is then provided, followed by suggestions on how to tailor aspects of exposure and response prevention to treat this specific form of OCD.

Violent obsessions are associated with suicidality in an OCD analog sample of college students

The picture of suicide in obsessive-compulsive disorder (OCD) is unclear because previous research did not uniformly control for depressive symptoms when examining the relationship between OCD and suicidality. Specific links between OC symptom dimensions and suicidality were also not adequately studied. As such, we investigated specific associations between OC symptom dimensions and suicidality, beyond the contribution of depressive symptoms, in an OCD analog sample of college students, a group traditionally at risk for suicide. One hundred and forty-six college students (103 females; 43 males) who exceeded the clinical cut-off for OC symptoms on the Obsessive-Compulsive Inventory, Revised (OCI-R) were recruited. Participants completed an online questionnaire containing measures that assessed suicidality and OC and depressive symptom severity. Total OC symptom severity, unacceptable thoughts, and especially violent obsessions exhibited significant positive zero-order correlations with suicidality. However, analyses of part correlations indicated that only violent obsessions had a significant unique association with suicidality after controlling for depressive symptoms. Our findings support the hypothesis that violent obsessions have a specific role in suicidality beyond the influence of depressive symptoms in an OCD analog sample of college students. A strong clinical focus on suicide risk assessment and safety planning in college students reporting violent obsessions is therefore warranted. Future related research should employ longitudinal or prospective designs and control for other possible comorbid symptoms in larger and more representative samples of participants formally diagnosed with OCD in order to verify the generalizability of our findings to these groups.

Evidence-Based Assessment of Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is a neuropsychiatric illness that often develops in childhood, affects 1%-2% of the population, and causes significant impairment across the lifespan. The first step in identifying and treating OCD is a thorough evidence-based assessment. This paper reviews the administration pragmatics, psychometric properties, and limitations of commonly used assessment measures for adults and youths with OCD. This includes diagnostic interviews, clinician-administered symptom severity scales, self-report measures, and parent/child measures. Additionally, adjunctive measures that assess important related factors (ie, impairment, family accommodation, and insight) are also discussed. This paper concludes with recommendations for an evidence-based assessment based on individualized assessment goals that include generating an OCD diagnosis, determining symptom severity, and monitoring treatment progress.

Assessing Sexual Orientation-Related Obsessions and Compulsions in Italian Heterosexual Individuals: Development and Validation of the Sexual Orientation Obsessive-Compulsive Scale (SO-OCS)

Sexual Orientation-Obsessive-Compulsive Disorder (SO-OCD) is characterized by intrusive thoughts, images, and urges related to one's sexual orientation, and by consequent avoidance, reassurance seeking, and overt and covert compulsions. Currently there is no short self-report measure that assesses SO-OCD symptoms. The current article describes two studies that develop and evaluate the first version of the Sexual Orientation Obsessive-Compulsive Scale (SO-OCS), a 14-item Italian self-report measure targeted towards heterosexual individuals. In Study 1, the SO-OCS was developed and refined through item analysis and exploratory factor analysis from an initial pool of 33 items administered to 732 Italian nonclinical participants. The SO-OCS showed a unidimensional structure and an acceptable internal consistency. In Study 2, the factor structure, internal consistency, temporal stability, construct and criterion validity, and diagnostic sensitivity of the SO-OCS were investigated in three samples of Italian participants (294 from the general population, 52 OCD patients who reported sexual orientation-related symptoms or concerns as a primary complaint, and 51 OCD patients who did not report these symptoms as primary complaint). The SO-OCS was again found to have a unidimensional structure and good internal consistency, as well as to exhibit strong construct validity. Specifically, the SO-OCS showed an excellent criterion validity and diagnostic sensitivity, as it successfully discriminated between those with SO-OCD and all other groups of participants. Finally, evidence of temporal stability of the SO-OCS in a nonclinical subsample was found. The SO-OCS holds promise as a measure of SO-OCD symptoms in heterosexual individuals.