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

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.

Prevalence and correlates of lifetime suicide attempt in obsessive-compulsive disorder with major depression

BACKGROUND

Little is known about specific obsessive-compulsive clinical features associated with lifetime history of suicide attempt in individuals with obsessive-compulsive disorder (OCD) and major depression.

METHODS

The study sample included 515 adults with OCD and a history of major depression. In exploratory analyses, we compared the distributions of demographic characteristics and clinical features in those with and without a history of attempted suicide and used logistic regression to evaluate the association between specific obsessive-compulsive clinical features and lifetime suicide attempt.

RESULTS

Sixty-four (12%) of the participants reported a lifetime history of suicide attempt. Those who had attempted suicide were more likely to report having experienced violent or horrific images (52% vs. 30%; p < 0.001). The odds of lifetime suicide attempt were more than twice as great in participants with versus without violent or horrific images (O.R. = 2.46, 95%, CI = 1.45-4.19; p < 0.001), even after adjustment for other risk correlates of attempted suicide, including alcohol dependence, post-traumatic stress disorder, parental conflict, excessive physical discipline, and number of episodes of depression. The association between violent or horrific images and attempted suicide was especially strong in men, 18-29 year olds, those with post-traumatic stress disorder, and those with particular childhood adversities.

CONCLUSIONS

Violent or horrific images are strongly associated with lifetime suicide attempts in OCD-affected individuals with a history of major depression. Prospective clinical and epidemiological studies are needed to elucidate the basis of this relationship.

The association between OCD and Shame: A systematic review and meta-analysis

BACKGROUND

Due to rumination and self-criticism over unwanted obsessions and repetitive rituals, shame is a common emotion experienced by individuals with obsessive-compulsive disorder (OCD). Shame is also theorized to have relevance to unacceptable thoughts in OCD. However, empirical research looking at the relationship between OCD and shame is still emerging and findings have been mixed.

OBJECTIVES

Our review systematically examines the association of shame with OCD and unacceptable thoughts.

METHODS

The last updated search was conducted across five databases between 27 and 29 February 2022. The final selection included 20 papers, 18 of which were used in the primary meta-analysis to calculate pooled effect sizes between OCD and shame measures using a random effects model. In a separate analysis, three papers were used to calculate pooled effect sizes between shame and OCD symptom dimensions also using a random effects model.

RESULTS

The meta-analyses identified a significant, moderate and positive correlation between total OCD and shame scores r = .352, 95% CI [0.260, 0.438]. In addition, significant, weak and positive relationships were found between shame and three OCD symptom dimensions: unacceptable thoughts r = .252, 95% CI [-0.467, 0.9708], harm obsessions r = .224, CI [-0.190, 0.638] and symmetry concerns r = .200, CI [-0.108, 0.509].

LIMITATIONS

Shame measures in the reviewed studies were not specific to OCD, and between-study variance in the analyses examining unacceptable thoughts was significant.

CONCLUSIONS

Our findings support a medium positive relationship between shame and OCD. As shame in OCD can be a barrier to seeking treatment and impair quality of life, it is imperative to address this emotion through psychoeducation, assessment and treatment.

Exploring predictors of aggressive intrusive thoughts and aggressive scripts: Similarities and differences in phenomenology

Experiencing a thought about harming or injuring another person is commonly reported by the general population. Aggressive intrusive thoughts (AITs) and aggressive scripts are two constructs commonly used to define the experience of thinking about harming another person. However, they are generally investigated separately and with two significantly different population groups; respectively, individuals with obsessive-compulsive disorder and people with a history of violent behavior. AITs and aggressive scripts are assumed to have very different implications for violence risk assessment, but conceptual overlap and an absence of empirical research renders this assumption premature. Using a battery of self-report measures, this study aimed to investigate the differential predictors of AITs and aggressive script rehearsal in a nonclinical sample. Additionally, using regression analyses, the predictors of self-reported aggressive behavior were explored in a sample of 412 adults (73% females; M_age  = 31.96 years, SD = 11.02). Violence-supportive beliefs and frequency of anger rumination predicted the frequency of aggressive script rehearsal, and aggressive script rehearsal, anger rumination, and violence-supportive beliefs predicted a history of aggressive behavior. In contrast, obsessive beliefs were predictive of AITs, and only AITs were related to ego-dystonicity. Both AITs and aggressive script rehearsal were related to the use of thought control strategies. These findings support the contributions that maladaptive beliefs have in the experience of aggressive scripts and AITs. Beliefs about violence, a history of aggressive behavior, and ego-dystonicity appear to differentiate aggressive scripts from AITs.

Impulsivity, hostility and suicidality in patients diagnosed with obsessive compulsive disorder

Background: There are limited data on suicidal behaviour in obsessive-compulsive disorder (OCD). This study aimed to evaluate several aspects affecting suicidality in OCD patients and determine whether impulsivity or hostility are associated with suicide attempts in this vulnerable group.Methods: Eighty-one patients with OCD were assessed by structured clinical interview for DSM-IV (SCID I), Yale-Brown Obsessive-Compulsive Scale (Y-BOCS), Suicide Probability Scale (SPS), Barratt impulsivity scale-11 (BIS) and Scale for suicide ideation (SSI).Results: Of the 81 patients, 22 (27%) had suicide ideation, 29 (33%) attempted suicides with OCD and 30 (37%) OCD patients who never experienced suicide ideation nor attempted suicide. Suicide ideation was associated with high hopelessness, higher severity of OCD and the presence of aggressive obsessions. On the other hand, suicide attempts were associated with longer duration of untreated illness, cognitive impulsivity, higher severity of OCD symptoms and the presence of religious obsessions.Conclusion: Higher severity of OCD symptoms is associated with both suicide ideation and attempts. And while hopelessness was related to suicidal thoughts, cognitive impulsivity may have acted as a facilitating factor for suicide attempts. Higher frequency of symptoms like religious/ aggressive obsessions was also associated with suicidality. It is vital that patients with OCD undergo detailed assessment for suicide risk.Key pointsOCD is associated with a high risk for suicidal behaviour.Suicide ideation was associated with high levels of hopelessness, OCD severity, and the presence of aggressive obsessions.Suicide attempts were associated with longer duration of untreated illness, cognitive impulsivity, severity of OCD, and the presence of religious obsessions.

Clinical features of scrupulosity: Associated symptoms and comorbidity

OBJECTIVE

Scrupulosity is a manifestation of obsessive-compulsive disorder (OCD) characterized by religious or moral core fears. Clinicians often struggle to treat scrupulosity, which may be associated with several features known to predict poor treatment outcome. The purpose of this study was to examine these features in participants with scrupulous OCD, contamination OCD, and healthy controls.

METHOD

A total of 68 participants (57.4% women, age_mean  = 34.01) completed diagnostic interviews, and measures of symptoms and quality-of-life.

RESULTS

Relative to comparison groups, scrupulous participants had higher rates of obsessive-compulsive personality disorder, more severe schizotypal symptoms, and more severe symptoms of depression. In addition, OCD severity was strongly associated with poor insight in the scrupulous group. Both OCD groups reported poorer quality of life than did healthy controls.

CONCLUSIONS

Clinicians working with scrupulous individuals may enhance the efficacy of treatment in this challenging population by assessing carefully for these features, and incorporating treatment elements that address them.

The relationship between left-behind experience and obsessive-compulsive symptoms in college students in China: the mediation effect of self-esteem

The number of left-behind children in China is gradually increasing, and college students with left-behind experience (LBE) have more severe mental health problems. The aim of this study was to evaluate the association of LBE and the obsessive-compulsive (OC) symptoms of college students, explore the mediation role of self-esteem in the relationship between them. A total of 4145 college students were recruited in Anhui province, China. The Chinese Obsessive-Compulsive Inventory-Revised (OCI-R) and Rosenberg Self-Esteem Scale (RSES) were used to measure OC symptoms and self-esteem. Bootstrap program was used to test the mediation effect. The results showed that the detection rate of OC symptoms was 24.1%. Multiple linear regression analyses found that LBE was positively associated with OC symptoms (t = 2.928, p = 0.003). High self-esteem scores in college students were significantly associated with a lower probability of OC symptoms (t = -17.023, p < 0.001). Furthermore, the test of Bootstrap showed that the indirect effect of self-esteem between LBE and OC symptoms was significant for 95% CI (LLCI = 0.3586, ULCL = 0.7264) and the mediation effect was 0.5396. The ratio of the indirect effect to the total effect was 0.408. OC symptoms were common mental health problems among college students. LBE had a positive predictive effect for OC symptomsand self-esteem plays a mediating role between them. Improving self-esteem will be beneficial to prevent and control the OC symptoms of college students.

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.

Psychache and Suicidal History in Patients with Obsessive-Compulsive Disorder

PURPOSE

Suicide is an important cause of death in patients diagnosed with obsessive-compulsive disorder (OCD) as well as other psychiatric disorders. Early determining of risk factors provides an opportunity for intervention. The mediating effect of psychological pain (also known as psychache) on suicide has been shown in various disorders but has not been investigated in patients with OCD. In this study, we aimed to show the relationship between psychological pain and other clinical variables and suicide in OCD patients.

PATIENTS AND METHODS

This cross-sectional study consisted of 67 patients diagnosed with OCD according to DSM-5 criteria with no comorbid psychiatric diagnosis who applied to the psychiatric outpatient clinic of Çukurova University Faculty of Medicine and 63 healthy controls. Among the OCD patients, 12 had previous suicide attempts. In addition to the sociodemographic data form, participants filled out the Yale-Brown Obsessive Compulsive Scale (YBOCS), the Psychache Scale (PS), the Beck Scale for Suicidal Ideation (BSIS), and the Hamilton Depression Scale (HDS).

RESULTS

OCD group's median obsession, compulsion, and the total scores of YBOCS, and the mean PS scores were higher than the control group. There was no difference between the sociodemographic variables of OCD patients with and without previous suicide attempts such as age, gender, years of education, place of residence, marital, and occupational status. The median scores of obsession, avoidance, global severity, and indecisiveness subdimensions of YBOCS, the mean BSIS and PS scores, the rates of current aggressive, current contamination, and the past religious obsessions were higher in the suicidal group. There were moderately significant relationships in the same direction between the PS, BSIS, and total YBOCS scores. Multivariate regression analysis demonstrated that only the PS scores predicted previous suicide attempts.

CONCLUSION

Our results demonstrated that current aggressive, current contamination, past religious obsessions, and the higher psychological pain are related to previous suicide attempts in OCD patients. Our regression analysis supports Shneidman's hypothesis: there would be no suicide without psychache. Relieving psychache in OCD patients may reduce suicide attempts even if there is no diagnosis of comorbid depression.

Treating Taboo or Forbidden Thoughts: Integrating Mindfulness, Acceptance, and Emotion Regulation Into an Exposure-Based Intervention

Individuals with obsessive compulsive disorder (OCD) who struggle with taboo or unacceptable obsessions (i.e., aggressive, sexual, or religious intrusions) tend to rely upon mental rituals to regulate their distress and possess difficulties labeling and regulating their affective state. Moreover, these individuals respond poorly to exposure with response prevention when the treatment is grounded in emotional processing theory. To improve patients' therapeutic outcomes, clinicians can consider integrating mindfulness- and acceptance-based skills into an exposure-based treatment to: facilitate the identification and acceptance of covert ritualistic urges, improve the accuracy of emotion labeling, and increase the efficiency of emotion regulation efforts. Additionally, in line with inhibitory learning theory, clinicians can design exposures to violate expectancies to promote the maintenance of long-term gains. Through a case vignette, the current article will demonstrate how to integrate these strategies into a standard exposure with response prevention intervention to meet the needs of a patient with taboo thoughts.

Directionality of change in obsessive compulsive disorder (OCD) and suicidal ideation over six years in a naturalistic clinical sample✰

BACKGROUND

Obsessive compulsive disorder (OCD) is associated with elevated suicide risk, but the directionality of the association between OCD severity and suicidal ideation has not been established, which was the goal of this study.

METHODS

Participants (n = 325) were adults with either a current or past diagnosis of Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) OCD who were assessed annually for suicidal ideation and OCD symptom severity for six years. Cross-lagged panel analyses statistically compared unidirectional and bidirectional models over time. Serious suicide-related adverse events were reported.

RESULTS

The best-fitting and most parsimonious model included paths predicting suicidal ideation from OCD symptom severity, but not vice versa. These results were confirmed by comparing a model with cross-lagged paths constrained equal to a freely estimated model. Higher OCD symptom severity in a given year was associated with a higher suicidal ideation severity in the subsequent year. Five suicide-related adverse events were reported throughout the duration of the study, including two suicide deaths and three suicide attempts.

LIMITATIONS

The study relied on a single-item, annual measure of suicidal ideation in adults, with substantial variability in severity of suicide risk, and missing data increased with later observations in the study.

DISCUSSION

OCD symptom severity predicted next year suicidal ideation severity. In contrast, suicidal ideation severity in a given year did not predict next-year OCD symptom severity in this OCD sample. Thus, rather than waiting for suicidal ideation to resolve, clinicians should consider providing empirically supported treatments for OCD.

Obsessive-Compulsive Disorder with Suicide Obsessions in a First Responder without Previous Diagnosis of OCD or History of Suicide Attempts

Obsessive-compulsive disorder (OCD) is a distressing and often debilitating disorder characterized by obsessions, compulsions, or both that are time-consuming and cause impairment in social, occupational, or other areas of functioning. There are many published studies reporting higher risk of suicidality in OCD patients, as well as studies describing increased risk of suicidality in OCD patients with other comorbid psychiatric conditions such as major depressive disorder (MDD) and posttraumatic stress disorder (PTSD). Existing case reports on OCD with suicide as the obsessive component describe patients with long standing diagnosis of OCD with suicidal ideations or previous suicide attempts. This report describes the case of a 28-year-old male, who works as a first responder, who presented with new onset symptoms characteristic of MDD and PTSD, with no past history of OCD or suicidality who developed OCD with suicidal obsessions. Differentiating between suicidal ideation in the context of other psychiatric illnesses and suicidal obsessions in OCD is critical to ensuring accurate diagnosis and timely provision of most appropriate treatment. The combination of exposure and response prevention therapy and pharmacotherapy with sertraline and olanzapine was effective in helping the patient manage the anxiety and distress stemming from the patient's OCD with suicidal obsession.

Early maladaptive schemas and suicidal risk in an Iranian sample of patients with obsessive-compulsive disorder

There are few studies on suicidal risk and its related factors in patients diagnosed with obsessive-compulsive disorder (OCD). This study investigated the associations of early maladaptive schemas, OC symptom dimensions, OCD severity, depression and anxiety with suicidality (i.e., suicidal ideation and suicide attempts) in OCD patients. Sixty OCD outpatients completed the Scale for Suicide Ideation (SSI), the Young Schema Questionnaire-Short Form (YSQ-SF), the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), the Dimensional Obsessive-Compulsive Scale (DOCS) and the Depression Anxiety Stress Scales (DASS-21). 51.7% of patients had lifetime suicide attempts and 75% had suicidal ideation. OCD patients with lifetime suicide attempts exhibited significantly higher scores on early maladaptive schemas than those without such attempts. Logistic regression analysis revealed that the mistrust/abuse schema and the OC symptom dimension of unacceptable thoughts explained lifetime suicide attempts. The mistrust/abuse schema, unacceptable thoughts and depression significantly predicted suicidal ideation. These findings indicated that the mistrust/abuse schema may contribute to high suicidality in OCD patients. Also, patients suffering from unacceptable thoughts need to be assessed more carefully for warning signs of suicide.

The relation of childhood trauma to suicide ideation in patients suffering from obsessive-compulsive disorder with lifetime suicide attempts

The aim of this study was to evaluate the relations of childhood trauma (CT) and obsessive-compulsive (OC) symptom dimensions to suicide ideation in patients with obsessive-compulsive disorder (OCD). Seventy OCD outpatients with lifetime suicide attempts and 60 controls were included. Participants completed the Scale for Suicide Ideation (SSI), the Childhood Trauma Questionnaire-Short Form (CTQ-SF), the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), the Dimensional Obsessive-Compulsive Scale (DOCS) and the Depression Anxiety Stress Scales (DASS-21). Among OCD patients, 97.1% had current suicide ideation. OCD patients revealed higher scores on CT, suicide ideation, depression and anxiety than controls. The CT history of sexual abuse (SA) and OC symptom dimension of unacceptable thoughts explained suicide ideation. It was concluded that SA and unacceptable thoughts may contribute to high suicidality and have important implications for the assessment and treatment of suicide risk in OCD patients with lifetime suicide attempts.