The relationship between obsessive beliefs and symptom dimensions in obsessive-compulsive disorder

Research findings on the specific relationships between beliefs and OCD symptoms have been inconsistent, yet the existing studies vary in their approach to measuring the highly heterogeneous symptoms of this disorder. The Dimensional Obsessive-Compulsive Scale (DOCS) is a new measure that allows for the assessment of OCD symptom dimensions, rather than types of obsessions and compulsions per se. The present study examined the relationship between OCD symptom dimensions and dysfunctional (obsessive) beliefs believed to underlie these symptom dimensions using a large clinical sample of treatment-seeking adults with OCD. Results revealed that certain obsessive beliefs predicted certain OCD symptom dimensions in a manner consistent with cognitive-behavioral conceptual models. Specifically, contamination symptoms were predicted by responsibility/threat estimation beliefs, symmetry symptoms were predicted by perfectionism/certainty beliefs, unacceptable thoughts were predicted by importance/control of thoughts beliefs and symptoms related to being responsible for harm were predicted by responsibility/threat estimation beliefs. Implications for cognitive conceptualizations of OCD symptom dimensions are discussed.     

Cognitive Beliefs Across the Symptom Dimensions of Pediatric Obsessive-Compulsive Disorder: Type of Symptom Matters

The cognitive model of obsessive-compulsive disorder (OCD) posits that dysfunctional cognitive beliefs are crucial to the onset and maintenance of OCD; however, the relationship between these cognitive beliefs and the heterogeneity of OCD symptoms in children and adolescents remains unknown. We examined how the major belief domains of the cognitive model (inflated responsibility/threat estimation, perfectionism/intolerance of uncertainty, importance/control of thoughts) and dysfunctional metacognitions were related to OCD symptoms across the following dimensions: doubting/checking, obsessing, hoarding, washing, ordering, and neutralization. Self-report ratings from 137 treatment-seeking youth with OCD were analyzed. When cognitive beliefs and symptom dimensions were analyzed in tandem, inflated responsibility/threat estimation and dysfunctional metacognitions were uniquely related to doubting/checking, obsessing, and hoarding and perfectionism/intolerance of uncertainty to ordering. Cognitive beliefs explained a large proportion of variation in doubting/checking (61%) and obsessing (46%), but much less so in ordering (15%), hoarding (14%), neutralization (8%), and washing (3%). Similar relations between cognitive beliefs and symptom dimensions were present in children and adolescents. Cognitive beliefs appear to be relevant for pediatric OCD related to harm, responsibility, and checking, but they do not map clearly onto contamination and symmetry-related symptoms. Implications for OCD etiology and treatment are discussed.     

Beliefs about obsessional thoughts

Recent cognitive-behavioral formulations of obsessive-compulsive disorder postulate that intrusive or obsessional thoughts are subject to appraisal. Extreme beliefs about the occurrence and meaning of intrusive thoughts direct appraisal, thus causing marked distress and subjective responsibility which may lead to neutralizing activity. A brief self-report belief inventory was developed from a 92-item pool to assess extreme beliefs concerning intrusive thoughts and responsibility, the control of such thoughts and their possible consequences, and the appropriateness of guilt and neutralizing behavior as a response. The inventory was developed sequentially on two nonclinical samples (N=125, N=265) to distinguish between neutralizing and nonneutralizing subjects. Initial psychometric data for the final instrument were obtained for two further nonclinical samples (N=61, N=50) along with a sample of OCD patients and a matched control group. The instrument showed satisfactory reliability and evidence of criterion, convergent, discriminant, and factorial validity. Finally, data from a heterogeneous outpatient medical sample (N=299) was used to test the relationship among obsessive-compulsive symptoms, mood state, and beliefs. The implications of these results for contemporary models of obsessive-compulsive disorder are discussed.     

The cognitive mediation of thought-control strategies

Research suggests that people use various strategies to control their normally occurring intrusive thoughts. Strategies that involve worrying about the thought and self punishment appear to be associated with certain forms of psychopathology, such as obsessive-compulsive (OC) symptoms. The present study sought to examine whether dysfunctional beliefs associated with OC symptoms (e.g., beliefs that intrusive thoughts are highly significant) underlie the use of such thought control strategies. Ninety-three non-clinical participants completed self-report questionnaires measuring cognitive variables, thought-control strategies, and OC symptoms. Analyses revealed that overestimates of threat and responsibility, beliefs about the significance and need to control intrusions, the need for perfection and certainty, and scrupulosity were associated with the use of punishment, but not worry thought control strategies. These cognitive phenomena also mediated the relationship between OC symptoms and the use of punishment as a thought-control strategy. Results are discussed in terms of cognitive models of OC symptoms and their implications for cognitive-behavioral therapy.     

Obsessional beliefs and the implicit and explicit morality of intrusive thoughts

Cognitive models of obsessive-compulsive disorder (OCD) suggest that misinterpreting intrusive thoughts exacerbates obsessional thinking. To evaluate this hypothesis, healthy participants (N=91) were prompted to recollect their unwanted thoughts, and then beliefs about the immorality of these thoughts were manipulated. Next, participants completed implicit and explicit measures of self-evaluation and appraisals of unwanted thoughts. Results from structural regression analyses indicated that explicit responses to unwanted thoughts, such as evaluations of the significance of intrusive thoughts and state self-esteem, were predicted by pre-existing obsessional beliefs, but not by the morality instruction manipulation. In contrast, implicit responses, such as appraisals of unwanted thoughts as relatively important and evaluations of the self as relatively immoral and dangerous, were predicted by the interaction between specific obsessional beliefs (e.g., intolerance of uncertainty) and the morality instructions. Findings largely support cognitive models of OCD and suggest unique predictors of implicit and explicit responses to unwanted thoughts.     

Do obsessional beliefs discriminate OCD without tic patients from OCD with tic and Tourette's syndrome patients?

There is considerable overlap in symptomatology between Tourette's syndrome (TS) and obsessive-compulsive disorder (OCD). Increased rates of tics are found in OCD and up to 60% obsessive-compulsive symptoms in TS. However, in OCD obsessive-compulsive symptoms are more often anxiety-related and, as a consequence, aimed at anxiety-reduction, whereas in TS these symptoms are more stimulus-bound. Therefore, it is of clinical interest to study whether these phenomenological differences are reflected in differences between dysfunctional cognitions accompanying OC symptoms in OCD with or without tics and TS. Current cognitive theory of OCD ascertains that specific dysfunctional beliefs are important in the etiology and maintenance of OCD. To assess these beliefs, the obsessive-compulsive beliefs questionnaire-87 (OBQ-87) has been developed. In the present study, OBQ-87 scores of OCD patients without tics, OCD with tics, and TS (without OCD) patients were compared to those of normal controls. Results: OCD without tic patients exhibited higher OBQ-87 scores than TS patients. No differences were found between OCD with or without tic patients on any of the OBQ-87 subscales. These results suggest that: (1) dysfunctional beliefs have no discriminative power with respect to OCD with or without tic patients; (2) the direct relationship between types of OC symptoms and specific dysfunctional beliefs is questionable. Therefore, one can doubt the specificity of cognitive theory of OCD to explain specific OC behavior.     

Clinical obsessions in obsessive-compulsive patients and obsession-relevant intrusive thoughts in non-clinical, depressed and anxious subjects: where are the differences?

Contemporary cognitive models of obsessive-compulsive disorder (OCD) assume that clinical obsessions evolve from some modalities of intrusive thoughts (ITs) that are experienced by the vast majority of the population. These approaches also consider that the differences between "abnormal" obsessions and "normal" ITs rely on quantitative parameters rather than qualitative. The present paper examines the frequency, contents, emotional impact, consequences, cognitive appraisals and control strategies associated with clinical obsessions in a group of 31 OCD patients compared with the obsession-relevant ITs in three control groups: 22 depressed patients, 31 non-obsessive anxious patients, and 30 non-clinical community subjects. Between-group differences indicated that the ITs frequency, the unpleasantness and uncontrollability of having the IT, and the avoidance of thought triggers obtained the highest effect sizes, and they were specific to OCD patients. Moreover, two dysfunctional appraisals (worry that the thought will come true, and the importance of controlling thoughts) were specific to OCD patients. The OCD and depressed patients shared some dysfunctional appraisals about their most disturbing obsession or IT (guilt, unacceptability, likelihood thought would come true, danger, and responsibility for having the IT), whereas the non-obsessive anxious were nearer to the non-clinical participants than to the other two groups of patients. The OCD patients showed an increased use of thought control strategies, with overt neutralizing, thought suppression, and searching for reassurance being highly specific to this group.     

Obsessional Beliefs and Symptoms of Obsessive–Compulsive Disorder in a Clinical Sample

The aim of the present study was to investigate the relationships among a broad range of obsessive–compulsive disorder (OCD) symptoms and obsessional beliefs in a clinical sample of OCD patients. Ninety-nine treatment-seeking adult OCD patients completed the Obsessive Beliefs Questionnaire and the Obsessive–Compulsive Inventory-Revised. Hierarchical regression analyses, controlling for comorbid symptoms, suggested that washing was predicted by responsibility/threat estimation beliefs. Checking/doubting was not predicted by any obsessional beliefs. Hoarding was predicted by perfectionism/certainty beliefs. Neutralizing was predicted by responsibility/threat estimation beliefs. Obsessing was predicted by importance/control of thoughts and perfectionism/certainty beliefs. Ordering was predicted by perfectionism/certainty beliefs. A principal components analysis of OCD symptom dimensions and accompanying beliefs yielded two components, accounting for 53% of the variance: one, which was labeled “Fear/Threat,” consisted of importance/control of thoughts, obsessing, responsibility/threat estimation, and washing. The second, which was labeled “Incompleteness/Not Just Right,” consisted of neutralizing, perfectionism/certainty, checking/doubting, and hoarding.     

Implicit and explicit appraisals of the importance of intrusive thoughts

To evaluate cognitive theories of obsessions, the current study experimentally manipulated appraisals of the importance of intrusive thoughts. Undergraduate students (N = 156) completed measures of obsessive-compulsive disorder (OCD) symptoms and beliefs and were primed with a list of commonly reported unwanted thoughts. Participants were then informed that unwanted thoughts are either (1) significant and indicative of their personal values, or (2) meaningless, or participants (3) received no instructions about unwanted thoughts. Participants then completed implicit and explicit measures of self-evaluation and interpretations of their unwanted thoughts. Results indicated that the manipulation shifted implicit appraisals of unwanted thoughts in the expected direction, but not self-evaluations of morality or dangerousness. Interestingly, explicit self-esteem and beliefs about the significance of unwanted thoughts were associated with measures of OCD beliefs, whereas implicit self-evaluations of dangerousness were better predicted by the interaction of pre-existing OCD beliefs with the manipulation. Results are discussed in terms of divergent predictors of implicit and explicit responses to unwanted thoughts.     

Dysfunctional cognitions mediate the relationships between religiosity,paranormal beliefs,and symptoms of obsessive-compulsive disorder

ABSTRACT

Research suggests that religious/paranormal beliefs are related to symptoms of obsessive-compulsive disorder (OCD), including scrupulosity (i.e., religious/moral obsessions and compulsions). However, the mechanisms that underlie these relationships are not well understood. This study focused on examining whether dysfunctional beliefs (DBs) mediate the relationships between: i) religiosity and OCD, ii) religiosity and scrupulosity, iii) paranormal beliefs and OCD, as well as iv) paranormal beliefs and scrupulosity. Students (n?=?775) completed a survey measuring religiosity, paranormal beliefs, OCD, scrupulosity, DBs (inflated sense of responsibility and over-estimation of threat [RT], intolerance of uncertainty and perfectionism [PC], and importance of and the need to control thoughts [ICT]), as well as depression and anxiety. Mediation analyses revealed that RT and ICT mediated all four relationships and PC mediated three of the four relationships. This suggests that paranormal and religious beliefs are associated with DBs which in turn may contribute to the severity of OCD.     

Cognitive control of obsessional thoughts

A defining characteristic of obsessive-compulsive disorder (OCD) is unsuccessful suppression of unwanted thoughts. Recent evidence of individual differences in ability to control intrusive thoughts may inform our understanding of failures of cognitive control associated with OCD symptomatology. The current study investigated characteristics of cognitive style that are potentially associated with OCD symptoms and may influence response to unwanted thoughts, including perceived ability to control thoughts and tendency to ruminate. Undergraduate students (N = 166) completed self-report measures of OCD symptoms, perceived thought control, and ruminative thinking. They were then presented with a distressing target thought and completed a standard thought suppression paradigm. Correlational results indicated that, controlling for anxiety and depression, OCD symptoms were positively associated with rumination and inversely associated with perceived thought control ability. In addition, OCD symptoms were associated with higher levels of distress and greater spontaneous efforts to suppress the target thought during a baseline period, while perceived thought control ability predicted frequency of target thoughts during suppression. Finally, results of the experimental manipulation confirmed that participants instructed to suppress experienced more intrusions during the recovery period. Clinical implications and future directions are discussed.     

The concealment of obsessions

Patients' deliberate concealment from others of the content and frequency of their obsessions is a common and important aspect of obsessive-compulsive disorder (OCD). It is an overlooked manifestation of the safety behaviour that is believed to sustain OCD (e.g., neutralizing, thought suppression, avoidance behaviour, concealment). The phenomenon of concealment is understandable in terms of the cognitive theory of obsessions which states that obsessions are caused when the person attaches catastrophic personal significance to their unwanted intrusive thoughts. It is suggested that the selected, planned, suitable disclosure of obsessions can be therapeutic--presumably because it exposes the patient to alternative interpretations of the significance of the unwanted thoughts.     

Appraisals of obsessional thoughts in normal samples

Cognitive theories of obsessive-compulsive disorder (OCD) posit that appraisals about the significance of thoughts are critical in the development and persistence of obsessions. Rachman [(1997). A cognitive theory of obsessions. Behaviour Research and Therapy, 35, 793-802.] proposes that appraisals of unwanted thoughts distinguish clinical obsessions from normal intrusive thoughts; thoughts appraised as important and personally significant are expected to be upsetting and recur. Appraisals are also expected to be related to symptoms of OCD. To explore the features of normal appraisals of obsession-like thoughts, nonclinical participants in two studies rated the personal significance of intrusive thoughts portrayed in vignettes containing prototypical themes associated with primary obsessions: aggressive, sexual, and blasphemous thoughts. Unwanted intrusive thoughts that were described as occurring more frequently were appraised as more personally significant, but participants appraised these socially unacceptable thoughts similarly whether they imagined having personally experienced them or a friend confiding about having experienced them. Appraisals in both studies were related to subclinical OC symptoms and OC beliefs.     

Role of thought-related beliefs and coping strategies in the escalation of intrusive thoughts: an analog to obsessive-compulsive disorder

Cognitive-behavioral models of obsessive-compulsive disorder (OCD) assume that obsessions have their origin in normal intrusive thoughts. These models propose that certain beliefs, such as thought-action fusion (TAF) beliefs, combined with the use of ineffective coping strategies, such as thought suppression, lead to the development of OCD. The purpose of the current study was to examine the relationship between these variables in a non-clinical sample in addition to exploring the effects of an alternative, acceptance-based coping strategy. This study explored the relationship between TAF beliefs, thought suppression, and OC-consistent symptoms via mediational analyses. Results showed that thought suppression mediated the relationship between TAF beliefs and OC-consistent symptoms. This study also experimentally examined the effects of various coping strategies (suppression, acceptance, or monitor-only) on the frequency of a distressing intrusion and appraisal ratings (e.g., anxiety, guilt, responsibility) after a TAF induction. Spontaneous suppression in the monitor-only group made comparisons of the experimental data difficult. However, analyses provided preliminary evidence suggesting that thought suppression is related to more intrusions, higher levels of anxiety, and negative appraisals, whereas an acceptance-based approach may be a useful alternative. Additional findings, limitations of the current study, and directions for future research are discussed.     

Are "obsessive" beliefs specific to OCD?: a comparison across anxiety disorders

Cognitive models of obsessive-compulsive disorder (OCD) assign a central role to maladaptive beliefs about threat, uncertainty, importance and control of thoughts, responsibility, and perfection. Previous research has demonstrated that such beliefs relate to specific OCD symptoms in a theoretically meaningful way. The aim of the present study was to determine whether these beliefs are endorsed more strongly by OCD patients than by those with other anxiety disorders. Eighty-nine adult OCD patients, 72 anxious control (AC) patients, and 33 nonclinical control (NCC) participants completed a measure of obsessive beliefs as well as measures of depression and trait anxiety. Compared to NCCs and ACs, OCD patients more strongly endorsed beliefs related to threat estimation, tolerance of uncertainty, importance and control of thoughts, and perfectionism, but not inflated responsibility. Using revised, condensed subscales, OCD patients differed from ACs on beliefs about perfectionism and certainty and about importance and control of thoughts, but not on beliefs about threat estimation and inflated responsibility. When controlling for depression and trait anxiety, the OCD and AC group did not differ on most belief domains, except for a belief that it is possible and necessary to control one's thoughts. Results are discussed in light of evolving cognitive-behavioral theories that highlight appraisals of thought control and the use and effectiveness of varying thought control strategies.     

Thought suppression in obsessive-compulsive disorder

Social cognition research has indicated that attempts to suppress thoughts can lead to a paradoxical increase in the frequency of that thought. This phenomenon has been a central component of cognitive-behavioural models of obsessive-compulsive disorder (OCD); however, research has yet to demonstrate deficient thought suppression ability in OCD patients. We examined whether individuals with OCD (OCs) exhibit a deficit in the ability to suppress thoughts. In Experiment 1, attempted thought suppression led to a paradoxical increase in self-reported thoughts for OCs, but not for nonanxious controls (NACs) or anxious controls (ACs). In order to rule out self-report biases, in Experiment 2 we utilized a lexical decision paradigm that measured priming strength of a target word under thought suppression conditions. Results paralleled those of Experiment 1: OCs showed decreased lexical decision latency of the 'suppressed' thought (thought to reflect either increased priming strength or disrupted processing of nonsuppressed thoughts), thus exhibiting a paradoxical effect of thought suppression. This effect was not seen in NACs or ACs. These findings suggest that deficits in cognitive inhibitory processes may underlie the intrusive, repetitive nature of clinical obsessions.     

Are there interactions among dysfunctional beliefs in obsessive compulsive disorder?

Contemporary cognitive models of obsessive-compulsive disorder emphasize the importance of various types of dysfunctional beliefs, such as beliefs about inflated responsibility, perfectionism and the importance of controlling one's thoughts. These beliefs have been conceptualized as main effects, each influencing obsessive-compulsive symptoms independent of the contributions of other beliefs. It is not known whether beliefs interact with one another in their influence on obsessive-compulsive symptoms. To investigate this issue, data from 248 obsessive-compulsive disorder patients were analyzed. Dependent variables were the factor scores on the 4 Padua Inventory subscales. Predictor variables were the factor scores from the 3 factors (inflated responsibility, perfectionism and controlling one's thoughts) of the Obsessive Beliefs Questionnaire and their 2- and 3-way interactions. Regression analyses revealed significant main effects; in almost all analyses one or more of inflated responsibility, perfectionism, and controlling one's thoughts factors predicted scores on the Padua factors even after controlling for general distress. There was no evidence that beliefs interact in their effects on obsessive-compulsive symptoms, thereby providing a relatively unusual instance in which a simpler explanation (main effects only) is just as powerful as a more complex model.     

Subtypes of obsessive-compulsive disorder: Implications for specialized cognitive behavior therapy

Although obsessive-compulsive disorder (OCD) is a heterogeneous condition, OCD subtypes have received limited attention in trials of cognitive behavior therapy (CBT). Because many patients with OCD do not respond optimally to CBT, it is important for clinicians to consider whether variability in treatment response is related to symptom presentation. Treatment modifications for patients without overt compulsions or with hoarding symptoms show promise. In this article we discuss the available research addressing the treatment of OCD subtypes, review the clinical characteristics and treatment recommendations for prominent OCD subtypes, raise the prospect of using dysfunctional beliefs as a potentially helpful conceptual approach to subtyping OCD and matching treatment to subtypes, and consider future directions in the treatment of OCD subtypes.     

Obsessive beliefs predict cognitive behavior therapy outcome for obsessive compulsive disorder

Cognitive accounts of obsessive compulsive disorder (OCD) assert that core beliefs are crucial to the development, maintenance, and treatment of the disorder. There are a number of obsessive beliefs that are considered fundamental to OCD, including personal responsibility, threat estimation, perfectionism, need for certainty, importance of thoughts, and thought control. The present study investigated if pretreatment severity of obsessive beliefs, as well as the change in obsessive beliefs following treatment, predicted intensive, residential cognitive behavioral therapy (CBT) treatment outcome. A series of hierarchical regression analyses were carried out to investigate the relations between obsessive beliefs and treatment outcome. Results indicated that inflated pretreatment responsibility/threat estimation beliefs were significantly related to less overall obsessive compulsive (OC) symptom reduction at discharge, explaining 2% of the overall variance. Changes in obsessive beliefs broadly, and importance/control of thoughts specifically, were positively related to overall OC symptom reduction at discharge, respectively explaining 18% and 3.6% variance. Results are modestly consistent with a number of theoretical models, which argue that inflated responsibility, threat estimation, and thought control are important to the maintenance and treatment of OCD.     

Inflated perceptions of responsibility and obsessive-compulsive symptoms

In Salkovskis' [Salkovskis, P. (1985). Obsessional-compulsive problems: a cognitive-behavioural analysis. Behaviour Research and Therapy, 28, 571-588; Salkovskis P. (1989) Cognitive-behavioural factors and the persistence of intrusive thoughts in obsessional problems. Behaviour Research and Therapy, 27, 677-682] cognitive model for obsessive-compulsive disorder (OCD), inflated perception of responsibility is highlighted as the critical feature that maintains the disorder. In the current study, the relationship between responsibility and obsessive-compulsive (OC) symptoms was examined. Specifically, three measures of responsibility were evaluated for their psychometric properties. These measures were then used to test Salkovskis's model by examining the relationships among pervasive responsibility, automatic thoughts related to causing harm, and OC symptom severity. Findings provide partial support for the validity and reliability of the measures and for the model as a whole. Based on regression analyses, data support that pervasive responsibility significantly contributes to the prediction of OC symptoms. Furthermore, this relationship appears to be mediated by automatic thoughts related to causing harm in OCD contexts.