The Relative Contributions of Experiential Avoidance and Distress Tolerance to OC Symptoms

Standardization of the Korean Version of the Acceptance and Action Questionnaire for Obsessions and Compulsions in University Students and Patients With Obsessive-Compulsive Disorder

OBJECTIVE

The Acceptance and Action Questionnaire for Obsessions and Compulsions (AAQ-OC) is a version of the Acceptance and Action Questionnaire (AAQ) that specifically measures unwanted intrusive thoughts and responses (e.g., experiential avoidance) to them. This study aimed to investigate the reliability and validity of the Korean version of the AAQ-OC in clinical and nonclinical Korean samples.

METHODS

In this study, 561 university students and 121 patients with obsessive-compulsive disorder (OCD) completed the AAQ-OC and several other psychological scales. Descriptive, correlation, and exploratory and confirmatory factor analyses as well as group comparisons were conducted.

RESULTS

The results of the exploratory and confirmatory factor analyses indicated a two-factor structure that best fits the data in the university sample: Factors 1 and 2 matched the original Valued Action and Willingness subscales, respectively. The reliability analyses revealed that the AAQ-OC and its factors had excellent internal consistencies. As regards the concurrent validity, the AAQ-OC and its factors had a positive correlation with the AAQ-II and Cognitive Fusion Questionnaire. Compared with the university students, the OCD patients had higher AAQ-OC scores, and their obsessive-compulsive symptoms, particularly the two symptom dimensions of responsibility for harm and mistakes and unacceptable thoughts, were significantly associated with the AAQ-OC and two subscales.

CONCLUSION

The findings of this study confirm the reliability and validity of the Korean version of the AAQ-OC.

Experiential avoidance as a mediator of risk factors for higher order internalizing psychopathology in the perinatal period

OBJECTIVES

Perinatal psychopathology can be damaging. This study examined the strength of the associations between risk factors and all perinatal mood and anxiety disorder symptoms while assessing the mediating effect of experiential avoidance.

METHOD

Participants (N = 246) completed assessments during pregnancy (28-32 weeks) and the postpartum (6-8 weeks). Structural equation modeling (SEM) was used to examine associations between risk factors and latent factors: distress (composed of depression, generalized anxiety, irritability, and panic symptoms); fear (social anxiety, agoraphobia, specific phobia, and obsessive-compulsive); and bipolar (mania and obsessive-compulsive).

RESULTS

During pregnancy, past psychiatric history, anxiety sensitivity, maladaptive coping, and age were significant risk factors. In the postpartum, negative maternal attitudes and past psychiatric history were only risk factors for symptoms that composed distress. Experiential avoidance mediated the relation between maladaptive coping and symptoms that composed fear.

CONCLUSION

It is important to assess for psychological risk factors starting in pregnancy. This study identified critical risk factors that are associated with the underlying commonality among perinatal mood and anxiety symptoms. Some of the risk factors as well as the mediator are malleable (negative maternal attitudes, experiential avoidance), creating new possibilities for prevention and treatment of perinatal mood and anxiety disorder symptoms.

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.

Childhood emotional maltreatment, maladaptive coping and obsessive-compulsive symptoms in patients with obsessive-compulsive disorder

Previous studies have reported childhood emotional maltreatment (CEM) to be associated with specific obsessive-compulsive (OC) symptoms, but maladaptive coping, which may be the underlying mechanism in this relationship, has not been evaluated yet. Thus, the present study aimed to examine the effects of CEM on the OC symptoms of responsibility for harm and unacceptable thoughts, as well as obsessive-compulsive disorder (OCD) severity, through maladaptive coping, including cognitive avoidance, experiential avoidance and emotional suppression in OCD patients (n = 360). The results showed that CEM had direct effects, as well as indirect effects via cognitive and experiential avoidance and emotional suppression, on responsibility for harm and unacceptable thoughts. In addition, the indirect effect of CEM on OCD severity was significantly mediated by the roles of cognitive avoidance and experiential avoidance. The present study adds new literature to evidence indicating the role of early childhood events in developing and maintaining OCD in which adverse maladaptive coping related to unpleasant childhood abuse plays an important role in OCD. More precisely, OCD patients who experience a history of CEM may further use maladaptive coping to cope with their distress and subsequently experience responsibility for harm, unacceptable thoughts and severe OCD.

A systematic review on the links between emotion regulation difficulties and obsessive-compulsive disorder

BACKGROUND

Growing evidence suggests a link between emotion regulation (ER) deficits and obsessive-compulsive symptoms (OCS).

AIMS

A systematic review was conducted to integrate empirical research on the nature of ER difficulties associated with obsessive-compulsive disorder (OCD), validated measures of ER for OCD and evidence base for psychological interventions targeting ER difficulties in OCD.

METHODS

Database searches were conducted on CINAHL, Cochrane Library, EMBASE, MEDLINE, PUBMED, PsycINFO and Scopus with keywords related to ER and OCD. 2609 articles were found, six were identified from other sources and 21 studies were included in this review. The review was registered on PROSPERO (CDR42020184076).

RESULTS

The non-acceptance of emotions was the most consistently related to OCS - albeit not uniformly with all OCS dimensions. There was also some evidence suggesting that difficulties in impulse-control, accessing effective ER strategies and engaging in goal-directed behaviours to be related to OCS. No OCD-specific ER measure was identified. Interventions with ER components appeared to be promising for the treatment of OCD.

FUTURE DIRECTIONS

Recommendations on how to build on the existing literature and improve the quality of evidence were provided.

Examining depression symptoms within OCD: the role of experiential avoidance

BACKGROUND

Obsessive compulsive disorder (OCD) and depression commonly co-occur. Past research has evaluated underlying mechanisms of depression in the context of other diagnoses, but few to no studies have done this within OCD.

AIMS

This study examines the relationships between distress tolerance (DT), experiential avoidance (EA), depression, and OCD symptom severity across intensive/residential treatment (IRT) for OCD. It was hypothesized that all variables would be significantly moderately related and EA would emerge as a potential contributing factor to change in depression and OCD symptoms across IRT for OCD.

METHOD

The sample included 311 participants with a primary diagnosis of OCD seeking IRT. Correlations were performed between all variables at both admission and discharge. A two-step hierarchical regression with change in OCD symptoms and change in DT in the first block and change in EA in the second block examined if change in EA explained change in depression above and beyond change in OCD and DT ability.

RESULTS

At both admission and discharge, higher EA, lower DT, and higher OCD symptom severity were significantly associated with more depressive symptoms. Change in EA explained a significant amount of variance in change in depression above and beyond change in OCD symptom severity and change in DT.

CONCLUSIONS

This study expands past results within an OCD sample, emphasizing EA as an important treatment target in OCD. Future studies could utilize samples from other treatment contexts, use a measure of EA specific to OCD, and utilize a longitudinal model that takes temporal precedence into account.

Association between obsessive-compulsive and related disorders and experiential avoidance: A systematic review and meta-analysis

The associations between the distinct types of obsessive-compulsive and related disorders and experiential avoidance have received mixed evidence. We, thus, undertook this meta-analysis to i) re-examine the association between obsessive-compulsive disorder and experiential avoidance, ii) extend this association to hoarding disorder, trichotillomania, and body dysmorphic disorder, and iii) identify potential variables affecting these associations. Five databases, including Medline, Embase, PsychINFO, Web of Science and CINAHL, were searched until March 15th, 2021. Meta-analyses based on random-effect models were performed. Heterogeneity and publication bias tests were applied using the I² statistic and the Egger's test. Meta-regression analyses were performed to identify potential moderators affecting the strength of these associations. Thirty-six unique studies based on n = 11,859 participants were identified. The association between obsessive-compulsive disorder and experiential avoidance was moderate (SMD = 0.75, 95% CI = 0.57-0.92), whereas the associations between individual obsessive-compulsive symptoms, including obsessions, responsibility for harm, ordering, checking, washing and neutralizing, and experiential avoidance ranged from low to strong (SMD ranged between 0.41 and 1.06, 95% CI = 0.25 to 1.40). The associations between hoarding disorder (SMD = 0.93, 95% CI = 0.46-1.40), trichotillomania (SMD = 0.56, 95% CI = 0.48-0.63), body dysmorphic disorder (SMD = 1.55, 95% CI = 0.72-2.37) and experiential avoidance were moderate to strong. Meta-regression analyses demonstrated that studies using the AAQ/AAQ-II scales for measuring experiential avoidance, and/or self-report scales for assessing OCRDs contributed smaller effect sizes. These findings suggest that reducing experiential avoidance may be a viable way of complementing exposure strategies in alleviating obsessive-compulsive and related symptoms.

Psychological Predictors of Anxious Responses to the COVID-19 Pandemic: Evidence from Pakistan

OBJECTIVE

COVID-19 epidemic can be associated with a variety of anxious responses and safety behaviors. The present research explored the psychological implications associated with COVID-19 during the outbreak in 2020 to date. Pakistani media has given particular attention to this outbreak in the region.

METHODS

Three hundred and forty-seven undergraduate university students from Pakistan completed a battery of questionnaires focusing fear of COVID-19, associated safety behaviors, factual knowledge of COVID-19, and other psychological pointers hypothesized to be as predictors of anxious responses to COVID-19 threat and associated safety behaviors.

RESULTS

The sample appeared to be fearful of COVID-19 and this fear was related to disgust sensitivity, anxiety sensitivity-related physical concerns, body vigilance, contamination cognitions, and general distress. Results suggested that the tendency of overestimating the severity of contamination and anxiety sensitivity towards physical concerns are significant predictors of COVID-19 related fear and consequent safety behaviors.

CONCLUSION

It is suggested that people with a greater concern of contamination are likely to respond fearfully to COVID-19 and that people with higher fear of COVID-19 are likely to feel contamination concerns.

Examining the role of cognitive fusion and experiential avoidance in predicting anxiety and depression

OBJECTIVES

Acceptance and Commitment Therapy (ACT) proposes that cognitive fusion and experiential avoidance are inter-related processes underpinning distress. This study investigated whether worry, rumination, and stressful life events on the one hand and anxiety and depression on the other hand were mediated by cognitive fusion and experiential avoidance (bidirectional serial association).

DESIGN

A questionnaire design was conducted cross-sectionally in a clinical sample (study 1; N = 57) and cross-sectionally and longitudinally in a non-clinical student sample (study 2; N = 106 and N = 97 respectively).

METHODS

Participants completed measures of worry, rumination, stressful life events (predictors), cognitive fusion, experiential avoidance (mediators), anxiety, and depression (outcomes) at T1. In study 2, anxiety and depression were measured again 6 weeks later.

RESULTS

In the clinical sample, the bidirectional relationship between experiential avoidance and cognitive fusion accounted for a significant proportion of the association between rumination and depression, and stressful life events and anxiety and depression. The association between worry and anxiety was mediated by cognitive fusion → experiential avoidance only. In the non-clinical sample, in both cross-sectional and longitudinal analyses, cognitive fusion independently mediated the association between predictors and outcomes, as well as the experiential avoidance → cognitive fusion pathway.

CONCLUSIONS

The bidirectional association between cognitive fusion and experiential avoidance was most predictive of distress in the clinical sample. In the non-clinical sample, cognitive fusion and the experiential avoidance → cognitive fusion pathway demonstrated more explanatory value. Given the cross-sectional nature of most of the data, the findings provide theoretical (as opposed to empirical) support for the models tested.

PRACTITIONER POINTS

Interventions designed to reduce cognitive fusion may be a useful early intervention for sub-clinical anxiety and depression. Interventions focused on reducing both cognitive fusion and experiential avoidance may be helpful for individuals presenting with clinical anxiety and depression. Individuals presenting with particularly high levels of experiential avoidance may benefit from initial work defusing from difficult thoughts, as an inroad for reducing experiential avoidance, anxiety, and depression. Likewise, those with rigid cognitive fusion may benefit from initial work around acceptance skills to create a context that better supports defusion.

Metacognitive beliefs mediate the relationship between anxiety sensitivity and traits of obsessive-compulsive symptoms

BACKGROUND

Metacognition has been shown as a key contributor to Obsessive Compulsive Disorder as well as other anxiety-related disorders, yet its role in the development and maintenance of these disorders remains unclear. This study aims to investigate whether anxiety sensitivity traits are related to obsessive-compulsive symptoms in the general population and whether the relationship between anxiety sensitivity and obsessive-compulsive symptoms is mediated by metacognition.

METHODS

Non-clinical volunteers (N = 156, mean age: 23.97, 121 females) completed measures related to state/trait anxiety, anxiety sensitivity, obsessive compulsive symptoms and metacognition.

RESULTS

A direct relationship between anxiety sensitivity and obsessive-compulsive symptoms was established. Further analysis revealed that metacognition was the strongest mediator of this relationship, even when accounting for state and trait anxiety.

CONCLUSIONS

Results suggest that the relationships between traits of anxiety sensitivity and obsessive-compulsive symptoms are partially attributable to the role of metacognition.

The Association of Trait Mindfulness and Self-compassion with Obsessive-Compulsive Disorder Symptoms: Results from a Large Survey with Treatment-Seeking Adults

Little is known about the role of mindfulness and self-compassion in obsessive-compulsive disorder. This cross-sectional study examined associations of mindfulness and self-compassion with obsessive-compulsive disorder symptoms and with the obsessive beliefs and low distress tolerance thought to maintain them. Samples of treatment-seeking adults (N = 1871) and non-treatment-seeking adults (N = 540) completed mindfulness, self-compassion, obsessive-compulsive disorder, anxiety, depression, obsessive beliefs and distress tolerance questionnaires. Participants with clinically significant obsessive-compulsive disorder symptoms reported lower trait mindfulness and self-compassion compared to participants with clinically significant anxiety/depression and to non-clinical controls. Among the clinical sample, there were medium-large associations between mindfulness and self-compassion and obsessive-compulsive disorder symptoms, obsessive beliefs and distress tolerance. Mindfulness and self-compassion were unique predictors of obsessive-compulsive disorder symptoms, controlling for depression severity. Once effects of obsessive beliefs and distress tolerance were controlled, a small effect remained for mindfulness (facets) on obsessing symptoms and for self-compassion on washing and checking symptoms. Directions for future research and clinical implications are considered in conclusion.

Using an Acceptance and Commitment Therapy Approach When Exposure and Cognitive Therapy Become Rituals in the Treatment of Obsessive-Compulsive Disorder

Exposure and response prevention (ERP) for obsessive-compulsive disorder (OCD) is often highly effective, yet some patients experience relapses following a seemingly successful course of treatment. In this article we describe the conceptual basis of ERP, and then present a client who relapsed after seemingly achieving substantial improvement following 11 sessions of ERP. Likely reasons for the relapse and strategies for enhancing ERP to achieve better long-term treatment outcomes are discussed from the perspective of acceptance and commitment therapy (ACT). These strategies mainly apply to the implementation of situational (in vivo) and imaginal exposure therapy, but also include suggestions for optimizing the use of cognitive therapy for OCD.

The importance of insight, avoidance behavior, not-just-right perception and personality traits in pediatric obsessive-compulsive disorder (OCD): a naturalistic clinical study

PURPOSE

The primary aim of the present explorative naturalistic study was to examine the association of poor insight, avoidance behavior, and not-just-right sensation with baseline parameters including obsessive-compulsive disorder (OCD) symptoms, baseline severity scores, comorbidity, and personality traits. A second aim was to examine how insight, avoidance and not-just-right sensation influence treatment outcome.

MATERIALS AND METHODS

In total, 317 medical records from children and adolescents with OCD referred to a specialized OCD clinic in Denmark were recorded for baseline parameters and treatment outcome. All information was used.

RESULTS

Avoidance behavior and poor insight were associated with an increased baseline severity, whereas not-just-right perception was not. Avoidance behavior was associated with the contamination/cleaning subtype, and a not-just-right sensation with the hoarding/symmetry subtype. Lower insight and avoidance behavior were associated with comorbid conditions. At post-treatment, not-just-right perception was associated with a risk of relapse, whereas lower insight was negatively associated with gaining remission. Avoidance behavior reduced the probability of remission and increased the number of offered sessions as well as and the likelihood of having SRI prescribed. Different personality traits were associated with treatment outcome.

CONCLUSION

Insight, avoidance behavior, and not-just-right perceptions seem important for baseline severity and post-treatment outcome. Baseline examination should include a systematic description, which could guide treatment. The present study is an explorative study describing a naturalistic clinical population. Therefore, a number of limitations should be taken into consideration when interpreting the results. More systematic studies on the importance of insight, avoidance behavior and not-just-right perceptions are warranted.

Does Experiential Avoidance Mediate the Relationship Between Gender Role Conflict and Psychological Distress?

Psychological inflexibility or experiential avoidance (EA) is an important construct in the understanding of psychological distress. Both EA and many forms of masculinity can be characterized by inflexibility in men’s responses to negative intrapersonal experiences. The current cross-sectional, community-based study investigated whether experiential avoidance mediated the relationship between gender role conflict (GRC) and psychological distress (PD). A total of 120 men (M = 35.63, SD = 12.22) completed an online questionnaire measuring key study variables. Results indicated that experiential avoidance significantly mediated the relationship between each of the four recognized patterns of GRC and PD. These findings suggest that EA may be a potential mechanism through which GRC is associated with PD.