The relationship between miscellaneous symptoms and major symptom factors in obsessive-compulsive disorder

The diverse symptomatology of obsessive-compulsive disorder (OCD) is being increasingly regarded as reducible to a few symptom dimensions. However, prevailing factor-analytically derived models of symptom structure omit a number of the well-recognized “miscellaneous” symptoms of OCD. This study sought to determine whether miscellaneous OCD symptoms, ascertained by the Yale-Brown Obsessive-Compulsive Scale symptom checklist, could be differentially and reliably predicted by four symptom factors (obsessions and checking, symmetry and ordering, contamination and cleaning, and hoarding) in two independent groups of individuals with OCD (n = 381 and n = 107). Logistic regression analyses were used to determine the association of each of the miscellaneous symptoms with the symptom factors; then a single confirmatory factor analysis was conducted to test the model of associations in the smaller sample. Sixteen (89%) of the 18 symptoms examined were reliably predicted by one (11 items) or two (5 items) of the factors, with obsessions and checking and symmetry and ordering emerging as foremost predictors. The expanded four-factor model showed good fit with data from the second sample. Results are conceptually meaningful, but suggest the inadequacy of groupings based solely upon overt behaviors. These findings may aid clinical understanding of OCD and be of value to studies using symptom factors to guide investigation of its causes and correlates.     

Associations between miscellaneous symptoms and symptom dimensions: an examination of pediatric obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) in children and adults is a heterogeneous disorder associated with significant psychosocial impairment. Although factor analytic studies have identified symptom dimensions, these analyses do not capture the varied miscellaneous symptoms that fail to load on a specific dimension despite being functionally related. The present study sought to extend the findings of previous research in adults to a sample of youth with OCD (n=131). Logistic regression analyses were used to examine the predictive value of each of the four symptom factors (contamination symptoms, obsessions and checking, symmetry and ordering, and hoarding) to the miscellaneous OCD symptoms. The vast majority of miscellaneous symptoms (17 of the 18 symptoms) were associated with one or more symptoms factors (i.e., contamination symptoms, obsessions and checking, symmetry, and ordering). Hoarding was not related to any miscellaneous symptom. In addition to improving our understanding about the clinical presentation of pediatric OCD, findings also have important assessment (e.g., understanding which miscellaneous symptoms relate to certain dimensions) and treatment implications (e.g., hierarchy development).     

Associations between miscellaneous symptoms and symptom dimensions in adults with obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a debilitating psychiatric condition with a heterogeneous array of obsessions and compulsions. Although factor analytic studies have identified symptom dimensions comprising the clinical presentation of OCD, many frequently reported miscellaneous symptoms are not considered in factor analytic studies because they do not fit conceptually within a particular symptom category, despite being functionally related. In the present study, we examined the associations between miscellaneous symptoms and OCD symptom dimensions in a sample of 111 adults with OCD. Overall, most miscellaneous symptoms were associated with one or more symptom dimensions in previously identified four- (14 of the 22 symptoms) and five-factor models (12 of the 22 symptoms). In both models, Contamination/Cleaning was the only dimension not related to any miscellaneous symptom. The present results provide information about which miscellaneous symptoms may be related to particular symptom dimensions, which will assist in clinical evaluations and help planning behavioral psychotherapy (e.g., hierarchy development).     

Associations between miscellaneous symptoms and symptom dimensions in adults with obsessive-compulsive disorder

Abstract

Obsessive-compulsive disorder (OCD) is a debilitating psychiatric condition with a heterogeneous array of obsessions and compulsions. Although factor analytic studies have identified symptom dimensions comprising the clinical presentation of OCD, many frequently reported miscellaneous symptoms are not considered in factor analytic studies because they do not fit conceptually within a particular symptom category, despite being functionally related. In the present study, we examined the associations between miscellaneous symptoms and OCD symptom dimensions in a sample of 111 adults with OCD. Overall, most miscellaneous symptoms were associated with one or more symptom dimensions in previously identified four- (14 of the 22 symptoms) and five-factor models (12 of the 22 symptoms). In both models, Contamination/Cleaning was the only dimension not related to any miscellaneous symptom. The present results provide information about which miscellaneous symptoms may be related to particular symptom dimensions, which will assist in clinical evaluations and help planning behavioral psychotherapy (e.g., hierarchy development).     

An investigation of traumatic life events and obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD), like most other psychiatric disorders, is suspected of being influenced by an interaction between life events and genes, both with regard to onset and course of illness. To date, no specific genes have been identified as playing a frequent role, and only a relatively few empirical studies have assessed the association between stressful life events (SLEs) and OCD. The present study builds on past research by examining the potential contributions from traumatic life events (TLEs) on the severity and symptom features in 265 individuals with Structured Clinical Interview for DSM-IV (SCID)-diagnosed OCD. Of these participants 54% endorsed having experienced at least one TLE in their life time. The presence of one or more TLEs was associated with increased OCD symptom severity. This relationship remained significant despite controlling for key variables including age, OCD age-of-onset, comorbidity, and depressive symptoms. In addition, obsessions/checking and symmetry/ordering were two of four symptom factors that were specifically associated with the occurrence of TLEs. These results are generally supportive of a pathoplastic relationship between TLEs and OCD symptomatology and thus suggest the need for greater systematic consideration of life stresses in research focused on the nature and treatment of OCD.     

Subtyping obsessive-compulsive disorder: A taxometric analysis

Obsessive-compulsive disorder (OCD) is a heterogeneous condition comprising multiple symptoms. Researchers have identified OCD subtypes using a range of symptom-based research methods, including factor and cluster analyses and examination of differential treatment response. These methods can be challenged on the grounds that they fail to demonstrate the existence of discrete taxonomic entities. Furthermore, no study has examined subtyping on the basis of cognitive characteristics. In the present study, the categorical vs. dimensional status of 6 possible subtypes of OCD was examined using taxometric methods. Three potential cognitive subtypes (based on high levels of responsibility/threat estimation, perfectionism/certainty, and importance/control of thoughts) and 3 potential symptomatic subtypes (based on elevated levels of contamination obsessions and cleaning compulsions, checking, and obsessionality) were examined using the MAXEIG and MAMBAC procedures in a sample of 404 diagnosed cases of OCD. Findings favored dimensional models of the potential responsibility, perfectionism, checking, and contamination subtypes, but offered qualified support for taxonic models of the importance/control of thoughts and obsessional subtypes. Implications for the subclassification of OCD are discussed.     

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.     

The structure of childhood obsessions and compulsions: dimensions in an outpatient sample

While obsessive-compulsive disorder (OCD) is defined as a unitary condition, prior research has identified meaningful and distinct symptom dimensions in adult samples. In contrast, there have been no investigations of symptom dimensions in samples of children diagnosed with OCD. The present study sought to address this gap. Children diagnosed with OCD (n = 137) were administered the Children's Yale-Brown Obsessive-Compulsive Scale symptom checklist and severity index. Symptoms were analyzed using principal components analysis. As with adult samples, four factors were identified from the checklist. However, these four factors (compulsions, sexual/aggressive obsessions, superstitions, and hoarding/ordering/somatic concerns) were different in content from adult studies. Further, several symptoms significantly contributed to more than one dimension. Each dimension was significantly correlated with scores from the severity index, with the exception of the obsession score with the hoarding/ordering/somatic concerns factor. Results suggest that there are distinct dimensions of symptoms in childhood OCD, but that these dimensions do not correspond to those identified in adults. Instead, it appears that some factors share variance, and the dimensions themselves are separated based upon developmental trajectories. The dimensions examined may be useful in future treatment studies using pharmacological and/or behavioral interventions.     

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.     

Clarifying the Placement of Obsessive-Compulsive Disorder in the Empirical Structure of Psychopathology

Recent work on the empirical structure of psychopathology has aimed to address some limitations that can arise from traditional categorical classification approaches. This research has focused on modeling patterns of co-occurrence among traditional diagnoses, uncovering a variety of well-validated dimensions (or spectra) of psychopathology, spanning common and uncommon mental disorders. A model integrating these empirically derived spectra (the Hierarchical Taxonomy of Psychopathology; HiTOP) has been proposed. However, the placement of obsessive-compulsive disorder (OCD) within this model remains unclear, as studies have variably found OCD to fit best as part of the Fear, Distress or Thought Disorder spectra. One reason for this may be the heterogeneity of symptoms experienced by individuals with OCD, which is lost when analysing categorical diagnoses. For example, different symptom clusters within OCD—such as washing and contamination versus obsessions and checking—may be differentially associated with different spectra in the HiTOP model. The aim of this study was to test this hypothesis. Data were collected in an anonymous online survey from community participants (n?=?609), largely with elevated symptoms of mental illness, and analyzed in a factor analytic framework treating OCD as a unitary construct and as four separate symptom clusters. The results indicated that OCD and its constituent symptom clusters had significant loadings of varying strength on the Fear and Thought Disorder spectra. These findings suggest that OCD may be best characterized as cross-loading on both the Fear and Thought Disorder spectra, and highlight the importance of accounting for diagnostic heterogeneity in future research.

     

Obsessive-Compulsive Disorder in Late Life

Although obsessive-compulsive disorder (OCD) has received increasing attention, the study and treatment of OCD in late life has been neglected. The obsessions and compulsions seen with older adults do not appear to differ from the symptoms experienced by other age groups, although developmental issues might influence symptom focus (e.g., memory functioning-related obsessions). Hoarding difficulties might be prevalent in late life, although additional studies are needed. Seniors with OCD can present with comorbid psychiatric disorders, multiple general medical problems, and impaired cognitive functioning, complicating evaluation. There have not been controlled clinical trials of cognitive-behavioral therapy (CBT) for late-life OCD, although initial reports suggest older adults respond to CBT that includes age-related treatment modifications. We illustrate the challenges to assessing and treating older adults with OCD with case examples involving memory-related obsessions and clinical hoarding. The successful strategies used for adapting CBT for the treatment of late-life generalized anxiety disorder might serve as a model for advancing the study and treatment of late-life OCD.     

Differential performance on the go/no-go task as a function of the autogenous-reactive taxonomy of obsessions: Findings from a non-treatment seeking sample

It has been suggested that obsessive-compulsive disorder is characterized by impaired inhibitory control. Response inhibition is a cognitive process required for one to cancel or suppress dominant but inappropriate responses. The present study examined response inhibition among non-treatment seeking individuals diagnosed with OCD and individuals with low levels of OCD symptoms using a computerized visual go/no-go task. Specifically, we sought to examine a prediction from the autogenous-reactive subtype model of obsessions (Lee, H.-J., & Kwon, S.-M. (2003). Two different types of obsession: autogenous obsessions and reactive obsessions. Behaviour Research and Therapy, 41, 11-29; Lee, H.-J., & Telch, M. J. (2008). Autogenous obsessions and reactive obsessions. In J. Abramowitz, S. Taylor, & D. McKay (Eds.), Obsessive-compulsive disorder: subtypes and spectrum conditions. New York: Elsevier., asserting that OCD individuals presenting with the autogenous subtype of obsessions will display greater difficulty in inhibitory control relative to individuals presenting with obsessions of the reactive subtype. Results showed that individuals with OCD of the autogenous subtype displayed more deficient inhibitory control on the visual go/no-go task as indexed by a longer response delay between the original stimuli set and the reversed stimuli set compared to individuals with OCD of the reactive subtype or individuals with low levels of OCD symptoms.     

The role of cognitive factors in the pathogenesis of obsessive-compulsive symptoms: a prospective study

Cognitive models of obsessive-compulsive disorder (OCD) posit that specific kinds of dysfunctional beliefs (e.g., pertaining to responsibility and the significance of intrusive thoughts) underlie the development of this disorder. The present study was designed to prospectively evaluate whether dysfunctional beliefs thought to underlie OCD act as a specific vulnerability factor in the pathogenesis of obsessive-compulsive symptomatology. Eighty-five individuals were prospectively followed over a period of time thought to be associated with an increased onset of OCD symptoms -- childbirth and the postpartum. The majority of these new mothers and fathers experienced intrusive infant-related thoughts and performed neutralizing behaviors similar to, but less severe than, those observed in OCD. Scores on a measure of dysfunctional beliefs thought to underlie OCD predicted the development of obsessive-compulsive symptoms after controlling for pre-existing OCD symptoms, anxiety, and depression. Dysfunctional beliefs also predicted the severity of checking, washing, and obsessional OCD symptom dimensions, but not neutralizing, ordering, or hoarding symptom dimensions. These data provide evidence for specific dysfunctional beliefs as risk factors in the development of some types of OCD symptoms.     

The status of hoarding as a symptom of obsessive-compulsive disorder

Hoarding is considered by many to be a symptom of obsessive-compulsive disorder (OCD). Yet although it is observed in people with OCD, hoarding symptoms also appear in a number of other psychological and psychiatric conditions. The present studies were conducted using samples of OCD patients, patients with other anxiety disorders, and a non-clinical sample to further elucidate the relationship between hoarding and OCD. Across two investigations, we found that (a) whereas OCD patients had higher scores than the other groups on non-hoarding symptoms, this was not the case for hoarding symptoms; (b) hoarding tended to correlate more weakly with other OCD symptoms (e.g., washing, checking) than these other symptoms intercorrelated; (c) items measuring hoarding had the weakest factor loadings when a measure of OCD symptoms was submitted to factor analysis; (d) hoarding symptoms were not correlated with global OCD or anxiety severity, whereas other OCD symptoms were; and (e) hoarding did not show consistent relationships with OCD-related cognitive variables. These results do not support a specific relationship between hoarding and OCD; and they call into question hoarding's status as a specific symptom of OCD. Results are also discussed in terms of the importance of functional assessment of hoarding and OCD symptoms.     

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.     

Special series Subtypes of obsessive-compulsive disorder: Introduction

An accumulating body of research suggests that obsessive-compulsive disorder (OCD) is a heterogeneous condition, yet there is not yet a consensus on how best to conceptualize subtypes or dimensions of the disorder. This special series considers theoretical and practical issues pertaining to OCD subtypes. New possibilities for conceptualizing differences among OCD patients are considered, and avenues for treating different presentations of obsessions and compulsions are discussed. Treatment programs continue to be refined and outcome studies continue to demonstrate that tailoring cognitive-behavioral treatment toward specific presentations of OCD (e.g., contamination fears, severe obsessions) represents the future of OCD treatment. The articles in this special series are intended to further efforts to consider ways of better understanding the heterogeneity of OCD.     

What Drives OCD Symptom Change During CBT Treatment? Temporal Relationships Among Obsessions and Compulsions

Cognitive behavior therapy (CBT) is an effective treatment for obsessive-compulsive disorder (OCD). However, less is known about how obsessions and compulsions change during treatment, either in tandem, sequentially, or independently. The current study used latent difference score analysis to show path-analytic dynamic modeling of OCD symptom change during CBT. Four competing models of the temporal relationship between obsessions and compulsions were examined: no coupling (obsessions and compulsions are not dynamically related), goal directed (obsessions lead to subsequent changes in compulsions), habit driven (compulsions lead to subsequent changes in obsessions), and reciprocal. Treatment seeking participants (N = 84) with a principal diagnosis of OCD completed 12 weeks of CBT group therapy and completed measures assessing obsession and compulsion severity at pretreatment, Sessions 4 and 8, and end of treatment. Bivariate results supported the goal directed traditional CBT model, where obsession scores are temporally associated with subsequent changes in compulsion scores. These results have implications for theoretical and treatment modelling of obsessions and compulsions in OCD treatment.     

The Yale-Brown Obsessive-Compulsive Scale: Confirmatory Factor Analytic Findings

The psychometric properties of the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) have recently been heavily examined. Specifically, a number of researchers have been interested in determining the factor structure of this scale to find whether it best forms a one, two, or three factor model. The present study continued this examination by considering different scaling models using confirmatory factor analysis with a sample of individuals diagnosed with Obsessive-Compulsive Disorder (OCD). One hundred and forty-six individuals diagnosed with OCD participated and were administered the Y-BOCS and scales measuring depression (Hamilton Depression Rating Scale) and anxiety (Hamilton Anxiety Rating Scale). It was found that the Y-BOCS forms two different two-factor models. One model consisted of an obsessions and compulsions factor; the other composed of disturbance and symptom severity factors. It was likewise found that depression and anxiety were related to both factors in one model (disturbance and symptom severity). The finding that depression was related to obsessions and anxiety to compulsions was found, as in a previous factor analysis of the Y-BOCS. These findings suggest that OCD may be best characterized as a multidimensional syndrome that may not be adequately examined by a single unitary factor as described in the Y-BOCS.     

Phenomenology of Early Childhood Onset Obsessive Compulsive Disorder

This paper describes the phenomenological features of early childhood onset obsessive compulsive disorder (OCD; defined as children meeting DSM-IV criteria for OCD with age of onset <8 years). Fifty-eight children (ages 4–8) were included in the sample. OCD and comorbid diagnoses were determined by structured interview, and OCD severity was measured using the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS). Mean age of OCD onset was almost five, and mean age of presentation was between 6 and 7. Mean symptom severity was in the moderately severe range. Comorbidity and family history of OCD were common. Contamination and aggressive/catastrophic obsessions and washing and checking compulsions were endorsed most frequently. Results indicate that early childhood onset OCD may have a lower boy to girl ratio and lower rates of depressive disorders, but may be similar to later childhood onset OCD in terms of OCD symptom presentation and severity.